A  CONSIDERATION  OF  THE 

PHENOMENA  WHICH   OCCUR  TO  WOMEN 

AT  THE  CLOSE  OF   THE  CHILD-BEARING  PERIOD, 

WITH  INCIDENTAL  ALLUSIONS  TO  THEIR  RELATIONSHIP 

TO  MENSTRUATION.     ALSO    A   PARTICULAR 

CONSIDERATION  OF  THE  PREMATURE 

(ESPECIALLY  THE  ARTIFICIAL) 

MENOPAUSE 


BY 

ANDREW   F.   CURRIER,   A.  B.,   M.  D. 

NEW    YORK   CITY 


NEW    YORK 

D.    APPLETON    AND    COMPANY 
1897 


C  <?7< 


COPYRIGHT,  1897, 
BY  D.   APPLETON  AND  COMPANY. 


J 

TO  i 

THE  MEMORY  OP  MY  DEAR  MOTHER, 

LONG  AT  REST, 

THIS  BOOK  IS  AFFECTIONATELY 
INSCRIBED. 


PREFACE. 


IT  is  many  years  since  an  original  work 
on  the  menopause  in  the  English  language 
has  appeared  before  the  public.  Tilt's  work 
upon  this  subject  was  long  the  only  one  of 
its  kind,  and  was  last  seen  in  a  reprint  pub- 
lished in  this  country  some  fifteen  years  ago. 
That  work  may  have  been  useful  in  its  day, 
but  it  contained  a  great  deal  of  statistical 
information  from  which,  as  it  seems  to  the 
writer  of  the  present  work,  unwarrantable 
deductions  have  been  drawn.  It  also  has 
handed  down  the  hoary  tradition,  which  has 
been  current  from  time  immemorial  among 
both  the  laity  and  the  profession,  that  the 
menopause  is  an  experience  fraught  with 
peril  and  difficulty.  This  and  all  similar 
teaching  the  writer  declares  to  be  incorrect 


VI 


PREFACE. 


and  unwarrantable  in  the  light  of  his  own 
experience  and  observation. 

Tilt's  book  is  further  defective  because 
the  great  fund  of  information  which  has 
accumulated  in  connection  with  the  artificial 
menopause  did  not  exist  in  his  time. 

A  translation  of  a  German  work  on  the 
menopause  by.  Borner  was  published  in  this 
country  about  the  same  time  as  the  reprint 
of  Tilt.  This  work,  though  very  brief,  is  a 
decided  improvement,  in  the  writer's  opinion, 
upon  Tilt.  It  seems  to  have  grasped  the 
subject  in  a  more  philosophical  and  scientific 
manner  than  the  work  of  Tilt,  but  is  deficient, 
nevertheless,  upon  certain  important  phases,  a 
comprehensive  study  of  which  has  only  been 
possible  within  the  past  few  years. 

The  writer  would  beg  leave  to  say  that  he 
has  had  the  subject  of  this  work  under  con- 
sideration many  years.  He  was  never  able  to 
see  the  sense  nor  the  logic  of  the  traditional 
teaching,  repeated  generation  after  generation, 
that  the  menopause  was  a  serious — yea,  even 
a  most  dangerous — time  and  experience  ;  that 


PREFACE.  vii 

the  matron  and  the  maid  alike  should  ap- 
proach it  with  fear  and  awe ;  that  if  this 
dangerous  Rubicon  were  once  passed,  joy  and 
felicity  would  wait  upon  the  remaining  years 
of  life. 

If  haemorrhage  were  exhausting  the  pa- 
tient, she  was  told  that  if  she  could  only  pass 
the  menopause  she  would  be  secure,  no  mat- 
ter whether  the  haemorrhage  were  due  to 
benign  or  malignant  disease,  and  if  the  meno- 
pause were  suspected,  too  often  the  doctor 
neglected  to  examine  his  patient  and  find  out 
— with  assistance,  if  unable  alone — whether 
the  disease  were  benign  or  malignant,  and 
whether  there  was  good  reason  for  thinking 
that  the  menopause  could  produce  a  cure. 
Now,  in  so  far  as  this  condition  of  opinion 
exists  at  the  present  time,  if  it  does  exist, 
either  in  the  lay  or  the  professional  mind,  to 
that  extent  the  writer  wishes  to  lift  up  his 
voice  in  earnest  protest.  The  menopause  is 
not  a  dangerous  time  or  experience  for  the 
majority  of  women,  any  more  than  puberty 
is.  The  majority  of  women  pass  through  it 


viii  PREFACE. 

with  as  little  incident  or  discomfort  as  they 
experience  at  puberty.  It  is  only  the  excep- 
tional woman  who  has  a  hard  time,  and  comes 
to  the  doctor  to  tell  him  about  it.  Upon  this 
exceptional  experience  the  doctrine  of  the 
danger  and  serious  character  of  the  meno- 
pause has  been  built  up. 

Another  serious  error  which  it  is  the 
writer's  desire  to  controvert  is  the  very  prev- 
alent one  that  there  is  in  some  way  the  most 
intimate  relationship  between  cancer,  espe- 
cially cancer  of  the  womb  and  the  breast,  and 
the  menopause.  That  many  cases  of  malig- 
nant disease  do  occur  during  the  decade  in 
which  the  menopause  usually  takes  place  is 
true.  While  this  number  is  probably  larger 
than  during  any  other  decade,  it  by  no  means 
includes  the  greater  number  of  all  cases,  and 
it  is  ridiculously  small  in  its  percentage  when 
compared  with  the  total  number  of  women 
who  undergo  the  experiences  of  the  meno- 
pause. Thus  the  principal  props  of  this 
threadbare  theory  of  the  dangerous  character 
of  the  menopause  are  seen  to  be  composed  of 


PREFACE.  ix 

the  flimsiest  material.  Let  us  knock  them 
down  and  bury  the  rubbish  out  of  sight  and 
memory. 

So  far  as  the  writer  is  aware,  little  or  no 
attention  has  been  given,  in  books  similar  to 
this  one,  to  the  subject  of  the  artificial  meno- 
pause. The  great  development  of  abdominal 
and  pelvic  surgery  within  the  past  generation, 
and  the  enormous  number  of  women,  tens  of 
thousands,  who  have  been  deprived  of  their 
ovaries,  for  one  reason  or  another,  has  opened 
up  a  rich  field  for  the  investigation  of  the 
phenomena  which  attend  the  removal  of 
those  important  organs.  It  is  hoped  that  the 
writer's  contribution  to  that  subject,  imper- 
fect as  it  is,  may  not  be  uninteresting  to  his 
professional  brethren,  and  may  perhaps  stimu- 
late some  one  who  may  be  better  qualified  to 
pursue  the  study  more  exhaustively. 

Concerning  the  question  of  the  treatment 
of  the  ills  of  the  menopause,  the  writer  earn- 
estly hopes  that  his  book  may  stimulate  those 
into  whose  hands  it  may  fall,  first,  to  a  more 
careful  and  systematic  investigation  of  those 


x  PREFACE. 

ills  than  has  been  the  usual  custom,  and,  sec- 
ond, to  an  early  resort  to  surgical  measures  if 
surgical  measures  are  indicated.  There  are 
many  cases  which  can  and  should  be  relieved 
by  such  measures,  and  it  is  hardly  just  or 
scientific  or  humane  to  load  them  down  with 
drugs  month  after  month,  in  the  most  em- 
pirical fashion,  if  the  condition  is  one  which 
can  be  effectually  and  permanently  relieved 
by  the  timely  resort  to  surgery. 

ANDREW    F.    CURKIEK,    M.  D. 

NEW  YORK,  March,  1897. 


CONTENTS. 


CHAPTER  I. 

PAGES 

HISTORICAL  AND  OTHER  PRELIMINARY  CONSIDERATIONS.    .  1-40 

On  the  choice  of  a  term,  1.  Relation  to  menstruation,  3. 
Menstruation  defined,  4.  Literature  of  the  subject,  views  of 
ancient  writers,  etc.,  5.  Modern  and  recent  writers  and  their 
scope,  10.  New  significance  to  the  subject  through  the  de- 
velopment of  abdominal  and  pelvic  surgery,  11.  Various  data 
concerning  the  menopause,  13.  The  menopause  should  be  a 
normal  function  or  experience ;  previous  teachings  to  the  con- 
trary are  erroneous,  14.  Amplified  definition,  15.  Exagger- 
ated views  concerning  the  menopause  as  a  critical  time  for 
good  or  evil,  16.  Views  of  Kisch  upon  the  subject,  with  analy- 
sis of  his  table,  18.  Analysis  of  Tilt's  table,  21.  Other  statis- 
tics, 22.  Explanation  of  possible  degenerative  changes  in  the 
tissues  during  the  menopause,  25.  Physical  condition  of  wom- 
an when  the  era  of  the  menopause  is  reached,  27.  Age,  28. 
Experiences:  1,  Normal,  28;  2,  Moderately  troublesome,  30 ; 
3,  Severe,  30;  4,  Serious,  32.  Table  of  cases  of  malignant 
disease  at  the  Skin  and  Cancer  Hospital,  33.  Classes  or  types 
of  women  in  conformity  with  the  above  classification,  35. 

CHAPTER  II. 

CONSIDERATIONS  CONCERNING  THE  ORGANS  OF  THE  GENITAL 
APPARATUS;  ANATOMICAL  CHANGES  RELATED  TO  THE 

MENOPAUSE 41-88 

1.  Anatomical  changes  which  are  the  result  of  the  meno- 
pause, 42.     2.  Anatomical  changes  which  produce  the  meno- 
pause, 42.     3.  Anatomical  changes  which  are  coincidental  with 
the  menopause,  but  not  usually  its  cause  or  caused  by  it,  42. 
xi 


xii  CONTENTS. 

PAGES 

Study,  in  detail,  of  the  changes  in  the  reproductive  organs 
which  result  from  the  menopause,  42.  1,  The  ovaries,  42; 
2,  The  uterus,  53 ;  3,  The  Fallopian  tubes,  vagina,  and  cli- 
toris, 62 ;  4,  The  mammary  glands,  64.  Changes  in  other 
structures  of  the  body,  66. 

Study  of  the  changes  in  the  reproductive  organs  which  lead 
to  the  menopause,  66.  1,  The  ovaries  and  Fallopian  tubes,  66 ; 
2,  The  peritonaeum,  70 ;  3,  The  uterus,  70 ;  4,  The  vagina,  75 ; 
5,  The  mammary  glands,  76. 

Study  of  those  changes  which  are  merely  coincidental  with 
the  menopause,  78.  Subin  volution,  79.  Malignant  disease,  etc., 
80.  Influence  of  destruction  of  the  genital  organs,  85.  Besume 
and  conclusions,  86. 


CHAPTER  III. 

SOME  OF  THE  FACTORS  WHICH  INFLUENCE  THE  ADVENT  AND 

PROGRESS  OF  THE  MENOPAUSE 89-186 

Scheme  of  treatment  of  the  subjects  in  this  chapter,  90. 
Unusual  activity  of  the  genital  organs  with  increased  vascu- 
larity  noticeable  at  the  beginning  of  the  menopause,  90. 
Changes  in  habit  and  temperament  as  the  menopause  pro- 
gresses, 91.  Factors  which  influence  the  menopause  vary  for 
different  women  and  affect  them  with  different  degrees  of 
force,  92.  Factors  :  1,  Age  ;  2,  Disease  and  traumatism  ;  3, 
Climate ;  4,  Heredity ;  5,  Temperament ;  6,  Accidental  influ- 
ences, 92. 

1.  Age  of  the  menopause  as  observed  by  the  author,  93; 
Kisch,  96 ;  Leudet,  96 ;  Tilt,  97 ;  Faye,  97 ;  Mayer,  97 ;  Burner 
and  others,  97.  Cases  of  early  menopause,  99.  Cases  of  late 
menstruation  by  Battey,  Felty,  and  others,  100.  Conclusion  as 
to  age  limits  for  the  cessation  of  menstruation,  102. 

2  Disease  and  traumatism  in  their  influence  upon  the 
menopause,  102. 

A.  (a)  Acute  inflammatory  processes,  'i 
(6)  Chronic         "  " 

B.  Degenerative  processes.  \  Classification,  103. 

C.  Neoplasms. 

D.  Trauma. 

Subdivisions  of  (A)  (a)  acute,  103,  and  (J)  chronic,  103,  in- 
flammatory processes.  The  acute  are  divided  into  (I)  gen- 


CONTENTS.  xiii 

PAGES 

cral  and  (II)  local,  the  latter  being  subdivided  into  (x)  puer- 
peral, and  (y)  non-puerperal,  ((c)  infectious,  (d)  traumatic). 

(b)  Chronic  inflammatory  processes,  108.  Wasting  diseases 
of  the  lungs  and  kidneys,  110.  Diseases  and  disorders  of  the 
nervous  system,  112.  Detailed  statements  concerning  the  in- 
fluence of  (B)  degenerative  processes,  atrophy,  obesity,  de- 
fective development,  115. 

Influence  of  (C)  neoplasms  on  the  menopause,  120.  Be- 
nign and  malignant,  121.  The  latter  tend  to  increase  the 
menstrual  flow  and  defer  the  menopause,  the  former  may 
hasten  it,  122. 

(D)  Trauma  as  a  factor  in  the  development  of  the  meno- 
pause, 130. 

3.  Climate,  including  altitude  and  atmospheric  conditions, 
131.     Observations  of  Leudet,  132,  Kisch,  133,  Bonier,  133, 
Lieven,  134,  Hannover,  134,  and  others  concerning  the  in- 
fluence of  climate,  133.    Influence  of  atmospheric  pressure,  1 36. 

4.  Heredity,  including    family,  national,    or  race   pecul- 
iarities, 139.    The  bearing  of  fertility  and  sterility  upon  the 
menopause,  143. 

5.  Temperament,  habits,  occupation,  and  social  surround- 
ings, 150.     Sexual  excess  and  abstinence,  155.     Concerning  the 
Oneida  Community,  159.    Prostitutes,  161.    Influence  of  sexual 
abstinence  upon  the  menopause,  166. 

6.  Accidental   influences,  fear,  emotion,   grief,  etc.,  167. 
Statistics  with  reference  to  conditions  bearing  upon  the  meno- 
pause, 169.    The  influence  or  bearing  of  the  menopause  upon 
ovulation  and  conception,  180. 


CHAPTER  IV. 

THE  PHENOMENA  OF  THE  MENOPAUSE,  NORMAL  AND  MORBID, 

AND  THEIR  DURATION 187-229 

The  type  of  experience  during  the  menopause  should  be 
a  condition  of  health ;  it  is  not  critical  in  the  sense  that  it  is 
dangerous  either  to  life  or  health,  187.  Phenomena  which  are 
common  to  the  menopause  and  others  which  are  less  common 
or  infrequent,  190.  Vasomotor  phenomena  and  their  types, 
191.  1,  Heat  flash:  2,  Sweating;  3,  Sweating  with  chill  or 
shudder  ;  4,  Headache  ;  5,  Melancholia  ;  6,  Chilliness  of  ex- 
tremities ;  7,  Abundant  discharge  of  urine  ;  8,  Diarrhoea  and 


xiv  CONTENTS. 

PAGES 

pelvic  congestion,  194.  Gastro-intestinal  disturbances,  es- 
pecially 1,  Constipation ;  2,  Intestinal  or  gastric  fermenta- 
tion ;  3,  Loss  of  appetite  and  indigestion,  etc ;  4,  Diarrhoea, 
194.  Pseudo-pregnancy,  195.  Anaemia,  196.  Haemorrhages, 
197.  Opinions  of  Scanzoni,  202;  Kisch,  202;  Frank,  203; 
Hegar,  203.  Lesions  of  the  mind  and  nervous  system  in  con- 
nection with  the  menopause,  204.  Observations  of  Merson, 
204,  and  Hegar,  205.  Hallucinations  and  sexual  ardor,  206. 
Climacteric  insanity,  investigations  and  investigators  in  this 
field,  207.  Lesions  of  the  skin  which  accompany  the  meno- 
pause, 218.  Cases  recorded  by  Grellety,  219,  Martineau,  220, 
Deligny,  221,  and  others.  Lesions  of  other  parts  or  organs, 
221.  Asthenopia,  222.  Gastric  troubles,  223.  Cardiopathies, 
223.  Other  lesions,  especially  those  of  a  functional  character, 
224. 

CHAPTER  V. 

THE  PREMATURE  MEXOPAUSE 230-266 

Definition,  230.  Relations  to  the  natural  menopause,  231. 
Disease  as  a  cause  may  be  constitutional  or  local,  231.  Other 
causes — climate,  heredity,  wasting  diseases,  231.  Excesses, 
poverty,  venereal  disease,  poisons,  obesity,  233.  Excessive 
fertility,  235.  Traumatism  as  a  cause,  236.  Artificial  meno- 
pause, 237.  Respective  claims  of  Battey  and  Hegar,  239. 
Indications  for  the  artificial  production  of  the  menopause, 
240.  1,  Inflammatory  disease  of  the  appendages,  241.  2, 
Neoplasms  of  the  appendages,  242.  3,  Ovarian  neuralgia  or 
dysmenorrhoea  if  severe  and  of  considerable  duration,  242. 
4,  Cases  in  which  Caesarean  section  has  been  required,  the 
natural  passages  being  entirely  incompetent  for  the  delivery 
of  a  viable  child,  243.  5,  Osteomalacia,  243.  6,  Severe  dis- 
ease of  the  uterus  which  can  be  relieved  by  no  less  severe 
measures,  243.  Insanity  and  epilepsy,  per  se,  not  indications, 
243.  The  phenomena  of  the  premature  menopause,  including 
those  which  accompany  operations  for  its  production,  244.  In 
some  cases  the  cessation  of  menstruation  is  the  only  symptom 
of  note,  in  others  the  symptoms  are  more  or  less  like  those 
which  come  with  the  natural  menopause,  244.  Glaevecke's 
investigations,  246.  Battey's  conclusions,  248.  Observations 
of  Hegar,  250.  Experience  of  the  author  in  this  field,  252. 
Removal  of  one  ovary  and  tube,  even  though  seriously  dis- 


CONTENTS.  xv 

PAGES 

eased,  does  not  bring  the  menopause,  253.  Kemoval  of  both 
ovaries  and  tubes  has  invariably  brought  the  menopause,  ex- 
cepting in  cases  of  uterine  myomata  with  attachments  to  sur- 
rounding structures,  254.  Atrophy  of  the  genital  organs  which 
remain  proceeds  rapidly,  256.  Influence  upon  the  sexual  appe- 
tite, 257.  The  operation  for  producing  the  menopause  does  not 
in  all  cases  relieve  the  pain  which  may  have  been  one  of  the 
chief  indications  for  its  performance,  but  the  pain  will  subside 
eventually,  259.  Effect  of  removing  the  ovaries  prior  to  pu- 
berty, 260.  The  analogous  operation  in  young  animals  may 
suggest  the  changes  which  might  occur  in  the  human  female, 
260.  Arrested  development  of  the  genital  organs,  261.  Ap- 
parent menopause  occurring  prematurely  from  disease,  from 
the  influence  of  sea  air,  262.  Propriety  and  utility  of  attempts 
to  restore  suspended  menstruation,  264.  Many  cases  entirel7 
hopeless,  265. 


CHAPTEE  VI. 

RETARDED  MENOPAUSE 267-269 

Definition  :  Cases  of  true  menstruation  beyond  the  fiftieth 
year  very  infrequent,  267.  Petrequin,  268.  Scanzoni's  limit, 
268.  (See  also  Chapter  III,  under  Age,  p.  101.)  Mayer's  cases, 
also  those  of  Kennedy,  Eodsewitch,  Sutherland,  268. 

CHAPTEE  VII. 

TREATMENT 270-283 

First  requisite  during  the  menopause  is  watchfulness  on 
the  part  of  both  patient  and  physician,  270.  Treatment  ia 
that  of  symptoms,  as  they  appear,  271.  Diet  should  be  sim- 
ple, bowels  kept  freely  open,  sedatives  given  as  indicated,  skin 
kept  active,  273.  Eemoval  of  blood  when  the  genitals  are  con- 
gested and  cause  erotism,  274.  Particular  attention  should  be 
given  to  the  haemorrhages  of  the  menopause  which  are  not 
physiological,  274.  Treatment  is  mainly  surgical,  275.  The 
means  which  may  be  of  use  are  the  electro-cautery,  curette, 
tampon,  etc.,  276.  Hysterectomy  is  indicated  if  the  symptoms 
are  severe  or  threatening,  277.  Astringent  drugs  sometimes 
beneficial  to  check  hiemorrhage,  277.  Treatment  of  the  neu- 


xvi  CONTENTS. 

roses  of  the  menopause,  especially  the  mental  disorders,  278. 
Depletive  measures  indicated,  also  hygienic  and  dietetic  meas- 
ures, 279.  For  treatment  of  neuralgias,  etc.,  consult  standard 
works  on  diseases  of  the  nervous  system,  280.  Cutaneous  le- 
sions treated  locally,  280.  For  other  lesions  see  works  on 
general  medicine,  282. 


THE    MENOPAUSE. 


CHAPTER  I. 

IIISTOKICAL    AND    OTHER    PRELIMINARY    CON- 
SIDERATIONS. 

Definition.— What  do  we  mean  by  the 
term  menopause?  Obviously  the  cessation 
of  the  menstrual  function.  But  is  that  all  ? 
By  no  means,  for  the  arrest  of  the  monthly 
discharge  of  blood  forms  but  a  single  inci- 
dent in  the  concatenation  of  events  which 
occur  in  the  experience  of  a  great  number 
of  women  who  reach  and  pass  the  limit  of  the- 
childbeariug  period. 

Want  of  Comprehensiveness  of  tlie  Term. — 
The  definition  which  has  been  given  is  there- 
fore lacking  in  comprehensiveness,  and  specifies 
only  one  of  the  most  noteworthy  and  impor- 
tant facts  which  occur  at  an  important  epoch 

in  a  woman's  life. 

2  l 


2  THE  MENOPAUSE. 

Substitutes  for  Term  employed  and  their 
Ambiguity. — Should  we  then  substitute  for 
menopause  the  term  change  of  life,  critical 
time,  climacteric,  etc.,  as  many  writers  have 
done  ?  No,  for  these  terms  involve  more  of 
ambiguity  than  does  menopause. 

The  change  of  life  is,  with  many  individ- 
uals, quite  as  definite  an  event  at  puberty  as 
at  the  end  of  the  period  which  is  inaugurated 
by  puberty — nay,  in  many  cases  that  change 
is  even  more  definite. 

Critical  times  occur  frequently  in  the  lives 
of  some  women,*  and  climacteric  merely  sub- 
stitutes a  synonym  of  Greek  origin  in  the 
place  of  critical  time  or  period. 

Obsolete  Terms.  —  Other  terms  such  as 
dodging  time,  climacteric  disease,  etc.,  have 
become  obsolete  for  various  good  reasons, 
and  need  only  be  mentioned. 

*  Several  periods  in  the  lives  of  both  men  and  women, 
and  not  identical  in  the  two  sexes,  have  been  determined  by 
different  writers  as  critical  or  climacteric  periods.  See  Hal- 
ford,  Medical  Transactions,  Royal  College  of  Physicians, 
London,  1813,  iv,  p.  316;  Connolly,  Dublin  Journal  of  the 
Medical  Sciences,  1844,  xxv,  p.  245;  O'Connor,  ibid.,  1875, 
Ix,  p.  78. 


PRELIMINARY  CONSIDERATIONS.  3 

The  Term  Menopause  to  he  employed. — 
On  the  whole,  while  admitting  the  narrow- 
ness of  its  etymological  scope,  the  term  meno- 
pause is  as  little  objectionable  as  any  that  is 
now  available,  and  will  therefore  be  em- 
ployed in  this  work  to  direct  the  mind  of  the 
reader  to  the  events  which  transpire  during 
those  months  and  years  in  the  life  of  a 
woman  when  the  childbearing  function  is 
drawing  to  its  close — a  period  forming  an 
isthmus  between  growth  and  decay,  a  lull 
between  flowing  and  ebbing  tides,  a  mile- 
stone to  mark  the  end  of  a  definite  period 
of  existence. 

Relation  to  Menstruation. — As  the  term 
which  has  been  thus  chosen  refers  definitely 
to  the  cessation  of  an  important  function,  no 
apology  will  be  deemed  necessary  for  such 
reference  to  and  consideration  of  that  func- 
tion as  may  have  a  bearing  upon  the  sub- 
ject in  hand;  at  the  same  time  no  attempt 
will  be  made  to  analyze  exhaustively  the 
various  interesting  propositions  in  histol- 
ogy and  physiology  with  which  it  is  in- 


4  THE  MENOPAUSE. 

timately  related,  in  which  both  speculation 
and  fact  are  abundant,  and  concerning 
which  there  still  remains  much  to  be 
learned.* 

Menstruation  defined.  —  As  a  working 
definition  of  menstruation  it  may  be  said  that 
it  is  a  function  common  to  females  of  the 
human  species  during  that  portion  of  life  in 
which  fruitfulness  is  a  characteristic.  It 
recurs  with  tolerable  regularity  each  lunar 
month  and  continues  the  greater  portion  of 
a  week.  Its  chief  objective  feature  is  a  dis- 
charge of  blood  from  the  uterine  canal  with 
which  epithelium  and  glandular  secretion 
from  the  uterus  and  vagina  are  mingled. 
With  the  discharge  are  frequently  associated 
phenomena  of  considerable  variety,  appertain- 
ing principally  to  the  vascular  and  nervous 
systems.  From  this  definition  the  many  ir- 


*  For  the  consideration  of  the  subject  of  menstruation,  es- 
pecially in  its  histological  aspect,  the  reader  is  directed  to  the 
writings  of  Leopold,  Wyder,  Moricke,  Kundrat  and  Engel- 
mann,  and  John  Williams,  and  for  an  exhaustive  considera- 
tion of  the  function  to  the  brochure  of  Dr.  Mary  Putnam 
Jacobi,  American  Journal  of  Obstetrics,  1885. 


PRELIMINAEY  CONSIDERATIONS.  5 

regularities  of  menstruation  which  are  possi- 
ble may  be  deduced.* 

Importance  of  Menstruation  has  been  ob- 
served for  Ages.— From  time  immemorial 
the  importance  of  the  menstrual  function  in 
women  has  been  a  recognized  fact  among 
critical  observers.  Its  significance  has,  of 
course,  been  differently  interpreted  by  ob- 
servers in  different  ages  and  in  different  con- 
ditions of  intellectual  development.  Among 
the  crude,  the  barbarous,  and  the  super- 
stitious the  solution  of  such  a  problem 
would  not  be  one  which  would  be  univer- 
sally satisfactory.  Even  among  highly  de- 
veloped nations,  like  the  Greeks,  the  inter- 

*  "The  menstrual  flow  is  due  to  the  influence  of  the  tubo- 
ovarian  (hypogastric)  plexus  which,  in  its  turn,  is  controlled 
by  the  solar  plexus.  The  uterus,  tubes,  and  ovaries  are  sup- 
plied by  the  hypogastric  plexus,  and  menstruation  must  con- 
tinue as  long  as  the  influence  of  this  plexus  continues.  With 
the  cessation  of  this  influence  the  flow  ceases  and  atrophy  of 
structure  begins.  The  radiating  currents  of  the  ganglionic 
centers  with  all  their  protean  reflex  actions  are  the  sources  of 
the  phenomena  of  the  climacteric.  When  they  are  no  longer 
needed  for  reproductive  purposes  they  expend  their  force  in 
every  conceivable  direction." — Nowlin,  The  Climacteric,  its 
Phenomena  and  Dangers,  Nashville  Journal  of  Medicine  and 
Surgery,  1895,  Ixxvii,  p.  7. 


6  THE  MENOPAUSE. 

pretation  could  not  be  expected  to  conform 
to  the  facts  because  of  imperfect  knowl- 
edge in  physiology  and  anatomy.  And 
among  the  observers  of  recent  times,  with 
incorrect  and  imperfect  views  of  pathology, 
menstruation  and  its  aberrations  must  neces- 
sarily receive  an  entirely  different  interpre- 
tation from  that  which  is  given  them  by  us 
who  enjoy  the  accumulation  of  the  knowl- 
edge of  all  previous  ages,  but  more  especially 
the  results  of  the  precise  investigations  of 
the  century  which  is  now  drawing  to  a 
close.* 

The  Egyptians,  who  investigated  so  many 
matters  concerning  the  human  body,  realized 
that  menstruation  was  an  important  function. 
This  is  shown  in  the  books  of  Moses,  much 
of  the  information  in  which  was  derived 

*  For  example,  Paracelsus  believed  that  the  menstmal 
blood  was  the  greatest  of  poisons,  and  that  with  it  the  devil 
produced  spiders  in  the  air;  also  that  fleas,  beetles,  cater- 
pillars, and  other  insects  were  generated  by  it.  Democrates 
in  his  Book  of  Antipathy  declares  that  all  those  caterpillars 
and  other  insects  which  destroy  a  garden  fall  off  and  die  if  a 
woman  with  her  menses  upon  her  walk  three  times  around 
each  quarter  of  the  garden  barefoot  and  with  her  hair  loose. 


PRELIMINARY  CONSIDERATIONS.  7 

from  Egyptian  sources,  and  in  which  a  men- 
struating woman  was  declared  ceremonially 
unclean,  coitus  with  her  being  forbidden,  etc. 

The  Menopause  not  carefully  observed  by 
most  of  the  Ancient  Writers. — But  while  the 
importance  of  menstruation  was  quite  gener- 
ally recognized  among  the  more  acute  of 
the  ancient  observers,  it  was  not  so  with 
the  menopause.  By  some  it  was  passed 
over  as  a  matter  occult  and  inexplicable, 
and,  in  general,  it  failed  to  receive  that  broad 
and  philosophic  treatment  with  which  so 
many  questions  were  discussed  by  the  an- 
cients. The  following  selections  will  show, 
however,  that  with  some  of  them  the  sub- 
ject had  not  escaped  their  attention. 

The  Humoral  Pathologists.—^l&s  humoral 
pathologists  believed  that  the  humors  or 
juices  ascended  like  gases,  and  that  they 
often  settled  in  the  brain  and  produced  great 
disorder,  which  required  the  abstraction  of 
blood  from  the  head,  arm,  foot,  or  other  part. 
In  the  cessation  of  the  menses,  either  tempo- 
rarily or  permanently,  they  saw  the  possibility 


8  THE  MENOPAUSE. 

of  serious  consequences,  and  they  are  prob- 
ably responsible  for  much  of  the  foreboding 
of  evil  which  is  associated  with  the  meno- 
pause in  the  minds  of  so  many  of  the 
laity* 

*  Amid  much  that  is  curious  in  the  writings  of  the  hu- 
moral pathologists  we  find  it  stated  by  Hoffmann,  one  of 
their  number,  that  if  venesection  is  omitted  when  the  menses 
cease,  violent  cardialgias  will  result,  accompanied  with  in- 
tense heat  and  pain  about  the  praecordia,  the  back,  and  scapu- 
lae, especially  in  the  nighttime.  Others  will  suffer  with  in- 
tolerable heat,  pain  in  the  joints,  and  erysipelatous  fevers, 
while  still  others  will  be  affected  with  nephritic  disorders 
accompanied  with  pain  in  the  loins,  and  terminating  in  cal- 
culous  concretions.  Furthermore,  some  women,  after  their 
sixtieth  year,  have  discharges  of  bloody  urine,  or  are  seized 
witli  an  immoderate  discharge  of  their  menses  which  at  last 
terminates  in  an  hectic.  Some  women,  especially  those  who 
are  wasted  by  prolonged  grief,  have  been  afflicted  with  pain 
in  the  left  hypochondrium  accompanied  with  uneasiness  and 
heat  of  the  praecordia,  which  afterward  terminates  in  a  vio- 
lent vomiting  of  blood  or  the  morbus  niger  of  Hippocrates. 
In  such  patients  upon  opening  their  bodies  the  spleen  has 
been  found  preternaturally  large  and  putrid,  the  vasa  brevia 
of  the  stomach  ruptured  and  gaping,  and  the  blood  discharg- 
ing from  these  vessels  into  the  ileum. 

James,  a  writer  of  the  early  part  of  the  eighteenth  cen- 
tury, states  that  unless  women  at  the  menopause  are  relieved 
by  seasonable  venesection  or  by  increasing  the  evacuations  of 
urine  or  transpiration,  they  generally  become  afflicted  with 
various  "chronical"  disorders. 

Hippocrates,  in  his  work  on  Diseases  of  Women,  says: 
"We  learn  from  experience  that  exulcerations,  violent  and 


PEELIMINARY  CONSIDERATIONS.  9 

Modern  Writers. — The  modern  literature 
of  the  subject  is,  of  course,  of  a  much  less 
sensational  character  than  the  ancient.  Its 
volume  is  not  large  when  compared  with  the 
literature  of  kindred  subjects  of  a  gynaeco- 
logical character,  the  latter  having  increased 
enormously  in  recent  years.  In  the  first  half 
of  this  century  appeared  a  number  of  papers 
and  volumes  treating  of  the  menopause,  prin- 
cipally by  French  authors,  only  two  of  which 
are  particularly  alluded  to  by  Tilt  in  his 
well-known  work  upon  this  subject. 

Gardanne  and  Menville. — One  was  by 
Gardanne*  and  was  published  in  1861,  and 
the  other  by  Menville,f  published  in  1840. 
Tilt's  opinion  of  these  works,  frankly  ex- 


even  scirrhous  tumors  of  the  uterus,  are  sometimes  produced 
by  cessation  of  the  menses.  Neither  do  the  external  parts  of 
the  body  escape  the  fatal  consequences  of  such  suppression, 
since  we  know  from  experience  that  by  this  means  they  are 
frequently  affected  with  the  itch,  the  elephantiasis,  boils, 
erysipelatous  disorders,  or  scirrhous  tumors." 

In  all  this  crude  material  there  is  the  shadow  of  very  im- 
portant truths. 

*  Avis  aux  Femmes'entrant  dans  1'Age  critique. 

t  Du  Temps  critique  chez  les  Femmes. 


10  THE  MENOPAUSE. 

pressed,  is  that  they  have  little  scientific 
merit.  A  review  of  the  remaining  literature 

O 

of  that  period,  so  far  as  it  was  accessible  to 
the  author,  did  not  impress  him  with  its 
importance. 

TiU.—Tilfs  work,  entitled  The  Change 
of  Life,  was  for  many  years  the  only  one 
upon  this  subject  available  for  readers  of  the 
English  language.  It  contains  a  vast  amount 
of  information  very  laboriously  prepared,  but 
aside  from  its  wealth  of  statistics  it  is  de- 
fective in  certain  particulars,  which  are  quite 
essential  to  the  comprehensive  treatment  of 
the  subject.  This  is  partly  for  the  reason 
that  important  data  relating  to  the  meno- 
pause, especially  when  artificially  produced, 
were  not  in  existence  when  the  book  was 
written. 

Kisch  and  Borner. — Kisch  and  Borner 
have  each  written  excellent  works  upon  the 
menopause  in  the  German  language,  and  an 
English  translation  of  Borner's  work  has 
been  published  in  this  country. 

The   recent  developments  in  pelvic  and 


PRELIMINARY  CONSIDERATIONS.          11 

abdominal  surgery  have  given  new  impor- 
tance to  the  subject.  The  fact  that  the  de- 
velopment of  pelvic  and  abdominal  surgery 
has  resulted  in  an  abrupt  change  of  the  cur- 
rent of  life  in  so  many  women  gives  to  the 
study  of  the  menopause  and  to  its  phe- 
nomena an  importance  which,  previous  to 
this  era,  they  did  not  have. 

Conclusions,  which  are  now  possible  as 
the  result  of  experience,  could  not  be  drawn 
by  Tilt  and  his  predecessors,  and  hence  the 
subject  is  invested  with  a  new  interest  and 
is  practically  placed  upon  a  new  foundation. 

VAKIOUS  DATA  CONCEROSTESTG  THE  MENOPAUSE. 

Analogue  of  Menstruation  in  Animals. — 
The  menstrual  period  has  its  analogue  in 
many  of  the  animals,  not  that  it  recurs  with 
the  same  frequency  or  regularity  as  with 
women,  but  it  is  manifested  by  a  congestion 
of  the  genital  organs,  a  disturbance  of  the 
nervous  system,  and  an  impulse  which  has 
a  very  manifest  relation  to  fruitbearing  or 
reproduction. 


12  THE  MENOPAUSE. 

If  coitus  and  conception  do  not  take 
place,  these  conditions  of  disturbance  disap- 
pear, to  return  again  after  a  longer  or  shorter 
period.  Every  one  is  familiar  with  such 
facts  as  these  in  the  domestic  animals.* 

Menopause  not  regarded  in  Animals  nor 
in  Women  of  Low  Type  or  Great  Physical 
Development. — The  analogue  of  the  meno- 
pause, especially  in  its  aberrations  and  dis- 
turbing elements,  is  not  seen,  so  far  as  the 
author  has  been  able  to  ascertain,  among  the 
animals. 

Among  those  human  beings  who  are  least 
removed  from  the  animals — the  savage  and 
the  degraded,  and  among  those,  too,  who  are 
subject  to  the  vicissitudes  of  out-of-door  life 
and  manual  labor — the  menopause  is  least 
likely  to  excite  attention  or  create  disturb- 
ance. It  is  among  the  highly  bred,  tenderly 


*  Such  facts  have  been  repeatedly  observed  in  the  pri- 
mates, apes  and  monkeys,  in  which  the  uterus  resembles  that 
of  women,  and  also  in  those  animals  in  which  the  uterus  is 
hollow — in  asses,  mares,  ewes,  sows,  bitches,  and  cats.  This 
observation  has  been  recorded  by  Buffon,  Cuvier,  Saint- 
Hilaire,  Ehrenberg,  Raciborski,  and  others. 


PRELIMINARY  CONSIDERATIONS.          13 

reared  women  of  civilized  life,  and  among 
those,  ±00,  who  have  experienced  an  undue 
share  of  the  ills  and  stings  of  life,  that  the 
menopause  is  a  matter  of  great  significance, 
not  infrequently  being  associated  with  a  gen- 
eral breaking  up  of  the  vital  forces  of  the 
individual. 

Menopause  should  be  a  Normal  Function 
or  Experience. — In  a  healthy  and  perfectly 
constructed  individual  the  functions  of  the 
body  are  performed  painlessly.  With  such 
an  individual  there  is  as  little  consciousness 
of  digestion,  or  of  the  very  existence  of  the 
stomach  as  a  particular  organ,  as  there  is  of 
things  in  general  during  natural  sleep. 

The  performance  of  menstruation  should 
be  accomplished  with  equal  ease,  and  the 
period  of  its  final  cessation  should  be  as  un- 
eventful as  that  of  its  beginning.  That  this 
is  not  the  case  in  many  instances  is  simply 
to  say  that  there  is  not  an  organ  or  function 
of  the  body  that  does  not  show  derangement 
and  disturbance  in  one  individual  or  another 
—indigestion,  dysmenorrhoea,  disturbed  rueno- 


14  THE  MENOPAUSE. 

pause,  and  a  thousand  other  ills  arising,  like 
the  miasm  from  the  marshes,  according  as 
the  conditions  favor. 

The  Abnormal  arouses  Attention. — It  is 
the  abnormal  in  Nature  which  most  impresses 
itself  upon  the  average  mind,  not  the  normal, 
and  the  serious  disturbances  which  have  hap- 
pened to  some  women  as  they  passed  through 
the  menopause  have  led  Tilt  and  others  to 
insist  upon  its  essential  seriousness  and  crit- 
ical character. 

Influenced  by  such  authority,  and  perhaps 
by  personal  observation  to  a  very  limited  ex- 
tent, the  public  at  large  has  come  to  look 
upon  this  experience  with  great  apprehen- 
sion, and  women  have  been  taught  that  they 
must  never  consider  themselves  quite  safe 
until  the  menopause  is  entirely  over  and 
passed. 

Past  Teaching  concerning  the  Menopause 
Erroneous  in  Many  Respects. — Such  teaching 
is  mischievous  and  irrational  in  the  light  of 
present  knowledge,  and  the  sooner  it  is  done 
away  with,  and  the  superstitions  of  the  past 


PRELIMINARY  CONSIDERATIONS.          15 

respecting  it  forgotten,  the  better  it  will  be 
for  humanity.* 

Definition. — We  may  define  the  meno- 
pause, therefore,  as  the  condition  which  exists 
and  the  collective  phenomena  which  appear 
in  connection  with  the  cessation  of  menstrua- 
tion. This  cessation  takes  place  gradually  in 
most  cases,  the  intervals  between  the  menses 
lengthening,  and  the  latter  finally  failing  alto- 
gether, after  a  period  of  from  one  to  three  or 
four  years.  During  this  time  the  phenomena 
are  varied  in  character.  With  some  women 
there  is  scarcely  any  consciousness  that  any. 
thins:  unusual  is  occurring,  aside  from  the 

o  "' 

fact    that    the    intermenstrual   intervals   are 

longer  than  usual.     With  others  the  hsemor- 

~ 

rhages,  if  less  frequent,  are  much  more  pro- 


*  Larousse  (Dictionnaire  universelle,  article  Menopause) 
notes  the  common  belief  among  women  that  the  menopause 
is  accompanied  with  grave  clangers,  but  he  considers  this  an 
error,  and  that  its  only  perturbations  are  slight  disorders  of 
the  stomach,  blushings  and  sweatings,  vertigo  and  headache. 
Sometimes  there  are  in  addition  pain  and  heaviness  in  the 
uterus,  lumbar  region,  and  vulva,  violent  pulse,  dyspnoea, 
palpitations,  haemorrhages,  hemorrhoids,  and  occasionally 
acne. 


16  THE  MENOPAUSE. 

fuse.  The  nervous  system  may  be  unaffected 
or  there  may  be  disturbance  of  both  cerebro- 
spinal  and  sympathetic  systems.  Vasomotor 
disturbances  are  extremely  common,  and 
mental  disturbances  are  by  no  means  rare. 
In  cases  in  which  there  is  predisposition  to 
the  development  of  new  growths,  such 
growths  may  develop  at  this  time. 

Atrophic  changes  take  place  in  all  the 
genital  organs  as  the  menopause  progresses. 

Finally,  the  menopause  may  be  as  un- 
eventful as  any  of  the  other  necessary  experi- 
ences to  which  the  female  economy  is  sub- 
jected, but  it  is  also  susceptible  of  varying 
as  far  as  possible  in  the  opposite  direction. 

EXAGGERATED  VIEWS  CONCERNING  THE  MENO- 
PAUSE AS  A  CRITICAL  TIME  FOR  GOOD  OR 
EVIL. 

We  are  all  more  or  less  in  bondage  to 

O 

tradition. 

Statements  which  have  been  handed  along 
the  ages  as  truth  and  fact  are  very  often  ac- 
cepted without  question  until  some  one  with 


PRELIMINARY  CONSIDERATIONS.          17 

a  probing  turn  of  mind  comes  along,  sifts  the 
story,  and  perhaps  succeeds  in  proving  that 
it  has  wandered  far  from  the  original — per- 
haps that  there  is  no  foundation  truth  in  it 
at  all. 

Tilt  accepts  the  Ancient  View  of  the  Seri- 
ous Character  of  the  Menopause. — The  notion 
that  the  menopause  always  signifies  a  serious 
or  critical  experience  is  of  respectable  antiq- 
uity, but  we  find  the  ancient  statements  re- 
lating to  it  overlaid  with  so  much  humbug 
and  nonsense  that  we  are  compelled  to  doubt 
the  correctness  of  the  original  observations. 

Perhaps  a  few  who  really  suffered  at  the 
menopause  were  observed  and  generalizations 
were  made  from  such  data.  At  any  rate,  the 
notion  has  come  down  to  our  time  and  finds 
in  Tilt  a  stanch  supporter. 

Suppose  we  compare  the  menopause  with 
any  of  the  ordinary  functions  of  the  body — 
with  digestion,  for  example.  Errors  of  di- 
gestion are  certainly  as  common  and  as  sig- 
nificant as  anything  that  can  be  associated 
with  the  menopause,  and  yet  we  can  not  con- 


18  THE  MENOPAUSE. 

sider  digestion  as  critical  in  any  sense,  nor  its 
aberrations  as  necessary  adjuncts  of  the  func- 
tion. 

Misleading  Character  of  KiscKs  Statis- 
tics.— How  misleading  are  such  statistics  as 
the  following,  which  are  taken  from  Kisch's 
book,*  and  which,  in  many  respects,  is  the 
best  book  that  has  been  written  upon  this 
subject : 

In  an  analysis  of  five  hundred  cases  of 
menopause  which  came  under  his  observa- 
tion, the  following  conditions  were  noted : 

Polymenorrhcea  or  metrorrhagia 286 

Chronic  metritis 79 

Leucorrhcea 327 

Prolapsus  uteri 65 

Ante-  or  retroflexion 52 

Pruritus  vaginae  or  vulvse 46 

Vaginismus 12 

Carcinoma  uteri 3 

Fibroma  uteri 5 

Tumor  mammae 8 

Three  out  of  every  five  in  these  five  hun- 
dred cases  are  said  to  have  suffered  with 
uterine  haemorrhage,  but  whether  it  was 

*  Das  klimakterisches  Alter  der  Frauen  in  physiologischer 
und  pathologischer  Beziehung,  Erlangen,  1874. 


PRELIMINARY  CONSIDERATIONS.          19 

sufficient  to  be  significant  or  serious  is  not 
apparent. 

Contrast  with  tlie  Author's  Experience. — 
Ainono;   those   whom    the    author    of    these 

O 

pages  has  seen  professionally  in  the  course 
of  the  menopause,  in  hospital,  dispensary, 
and  private  practice,  who  were  not  suffering 
with  pelvic  or  abdominal  tumors  or  with 
some  other  legitimate  cause  for  haemorrhage, 
the  number  who  have  suffered  with  this  most 
loudly  heralded  bugbear  of  the  menopause 
has  been  insignificant.  This  suggests  that 
the  fact  should  not  be  overlooked  that  the 
great  majority  of  women  who  survive  to  old 
age  never  consult  a  physician  in  regard  to 
the  menopause,  and  that  of  these  nothing  is 
said  in  tables  of  statistics,  such  tables  includ- 
ing only  those  who  require  the  physician's 
aid. 

Chronic  Metritis  and  Leucorrhwa.— 
Chronic  metritis  is  a  condition  so  indefinite 
in  character  that  the  seventy-nine  cases  in 
this  table  may  have  suffered  much  or  little 
with  it.  As  a  marked  accompaniment  of  the 


20  THE  MENOPAUSE. 

menopause,  the  author  has  had  little  experi- 
ence with  it.  If  by  this  term  the  condition 
of  endoinetritis  is  meant,  it  would  seem  to 
the  author  that  its  gravity  and  importance, 
not  only  in  relation  to  the  menopause,  but  in 
general,  had  been  greatly  overestimated  in 
recent  years,  the  profoundly  infectious  vari- 
ety being  excepted. 

Leucorrhoea  is  also  a  most  indefinite  term, 
and,  with  the  exception  of  the  infectious  va- 
riety, would  not  seem  to  the  author  a  serious 
complication  of  the  menopause.  That  three 
hundred  and  twenty-seven  of  the  five  hun- 
dred cases  in  the  table  should  suffer  with  it 
can  be  easily  comprehended,  for  there  are 
few  women,  at  any  period  of  life,  in  whom  it 
may  not  be  found,  in  greater  or  less  degree, 
if  one  wishes  to  find  it. 

Displacements  of  the  Uterus. — That  sixty- 
five  should  have  suffered  with  prolapsus  uteri 
seems  a  large  percentage — much  larger  than 
one  would  find  in  American  women,  espe- 
cially if  the  prolapse  were  considerable. 

Whether  these  figures  apply  only  to  mar- 


PRELIMINARY  CONSIDERATIONS.          21 

ried  and  parous  women,  and  whether  they 
include  those  cases  in  which  the  vaginal  walls 
alone  were  prolapsed  and  in  which  the  uterus 
had  not  descended  beyond  the  vulva,  is  not 
apparent.  Neither  this  nor  the  succeeding 
three  items — ante-  and  retroflexion,  pruritus 
vaginae  or  vulvse,  and  vaginismus — can  fairly 
be  taken  as  the  basis  for  any  argument  spe- 
cifically directed  against  the  menopause,  since 
they  are  quite  as  common,  perhaps  more  so, 
in  the  years  which  precede  the  menopause. 

Neoplasms. — With  reference  to  carcinoma 
uteri  and  fibroma  uteri  and  tumor  manimsB, 
the  number  of  cases  in  the  table  is  very 
small,  and  yet  these  are  the  very  conditions 
which  the  older  writers  have  dreaded  as  the 
particular  concomitants  of  the  menopause. 
If,  therefore,  it  is  assumed  upon  the  testi- 
mony of  this  table  that  the  menopause  is  a 
dangerous  and  critical  time,  we  are  forced  to 
enter  a  plea  of  not  proven. 

Tilt1  s  Statistics.— In  Tilt's  work  on  The 
Change  of  Life  we  also  find  a  table  in  which 
there  are  statistics  of  five  hundred  cases, 


22  THE  MENOPAUSE. 

which,  he  says,  were  observed  in  the  higher 
classes,  socially,  in  England  in  the  course  of 
twenty-five  years  of  practice.  In  addition  to 
such  minor  complaints  as  sick  headache,  bil- 
iousness, diarrhoea,  deafness,  neuralgia,  ery- 
sipelas, etc.,  he  has  tabulated  such  conditions 
as  the  following : 

Insanity 16 

Paraplegia  6 

Apoplexy  and  hemiplegia 6 

Fibroma  uteri 4 

Carcinoma  uteri 5 

Heart  disease   1 

Carcinoma  mammae 1 

That  is,  of  malignant  disease  of  the  geni- 
tal organs  only  a  fraction  over  one  per  cent 
was  noted  by  this  ardent  advocate  of  the 
serious  character  of  the  menopause,  while  of 
mental  disease  there  was  only  a  fraction  over 
three  per  cent.  The  other  complications 
may  be  excluded,  for  it  is  improbable  that 
they  were  essentially  related  to  the  meno- 
pause. 

United  States  Census  Statistics. — In  the 
vital  statistics  of  the  United  States  census 
for  1880  there  were  reported  48,950  deaths 


PRELIMINARY  CONSIDERATIONS.          23 

of  women  between  the  ages  of  forty  and 
fifty,  out  of  a  total  of  4,558,226  women  of 
the  respective  ages.  Of  this  number  there 
were  1,771  deaths  from  cancer,  about  one 
quarter  of  them  being  cases  of  cancer  of  the 
genital  organs.  That  is,  less  than  one  per 
cent  of  the  women  who  died  in  the  United 
States  from  1870  to  1880  between  the  ages 
of  forty  and  fifty,  the  usual  period  of  the 
menopause,  died  from  cancer  of  the  genital 
organs. 

Mortality  from  Malignant  Disease  of  the 
Genital  Organs  during  the  Menopause. — Of 
course,  allowance  must  be  made  in  statistics 
of  this  character — which  can  hardly  be  ex- 
pected to  have  the  merit  of  scientific  accu- 
racy— for  errors  of  diagnosis ;  while,  on  the 
other  hand,  it  will  also  be  admitted  that  no 
inconsiderable  number  of  cases  of  these  varie- 
ties are  never  reported.  But,  inasmuch  as 
the  percentage  of  fatal  cases  is  about  the 
same  as  is  recorded  in  the  statistics,  it  seems 
fair  to  conclude  that  the  mortality  from  ma- 
lignant disease  during  the  period  of  the  men- 


24  THE  MENOPAUSE. 

opause  does  not  greatly  exceed  one  per  cent. 
This  can  not  be  said  to  make  of  the  meno. 
pause  a  period  which  should  be  especially 
dreaded  on  this  account. 

Neuroses  of  the  Menopause. — Concerning 
the  neuroses  of  the  menopause  there  is  much 
to  be  said,  which  will  appear  at  a  later  period 
in  this  discussion.  It  may  be  remarked,  in 
passing,  that  Krafft-Ebbing  refers  seven  per 
cent  of  cases  of  insanity  in  women  to  disturb- 
ance which  is  associated  with  the  menopause ; 
in  Meynert's  clinic  the  climacteric  was  re- 
garded as  an  getiological  factor  in  sixteen  out 
of  one  hundred  and  twenty-six  paralyzed 
women. 

Conclusions  of  Various  Writers. — Of  the 
many  who  have  expressed  an  opinion  at  one 
time  or  another  concerning  the  various  phe- 
nomena of  the  menopause,  Tissot,  Dewees, 
Meissner,  Saucerotte,  Landouzy,  and  a  num- 
ber of  recent  American  writers  deny  that 
they  indicate  especial  gravity  as  to  the  con- 
dition, while  Fothergill,  Clarke,  Meigs,  Bed- 
ford, Lisfranc,  Boivin,  Dupuytren,  Velpeau, 


PRELIMINARY  CONSIDERATIONS.          25 

and  others  support  Tilt  in  his  contention  that 
they  do  indicate  such  gravity. 

Tilt  modifies  his  statement,  however,  by 
admitting  that  critical,  with  reference  to  the 
menopause,  does  not  necessarily  mean  fatal. 

More  Extensive  Knowledge  concerning 
the  Menopause  than  our  Predecessors  had 
leads  us  to  fear  it  less  than  they  did. — It 
is  possible  that  our  increased  knowledge 
concerning  the  phenomena  of  the  meno- 
pause, together  with  our  improved  methods 
of  treating  them,  leads  us  to  take  the  less 
gloomy  view  of  the  situation  compared  with 
many  of  those  who  have  studied  the  sub- 
ject in  the  past. 

Possible  Explanation  of  Degenerative 
Changes  during  the  Menopause.  —  Exagger- 
ated and  incorrect  as  it  is  believed  many  of 
the  notions  concerning  the  menopause  have 
been,  it  is  admitted  that  serious  conditions 
may,  and  sometimes  do,  develop  in  the  genital 
organs  at  that  time.  This  may  be  accounted 
for  as  follows :  When  the  period  of  fruit- 
fulness  is  ended  the  activity  of  the  tissues 


26  THE  MENOPAUSE. 

has  reached  its  culmination,  the  secreting 
power  of  the  glandular  organs  begins  to 
diminish,  the  epithelium  becomes  less  sensi- 
tive and  less  susceptible  to  infectious  influ- 
ences, and  atrophy  and  degeneration  take  the 
place  of  the  active  up-building  processes. 

In  the  presence  of  an  irritant,  scar  tissue 
for  example,  or  that  vague  condition  of  sus- 
ceptibility which  we  call  a  diathesis  or  dys- 
crasia,  tissues  which  under  ordinary  con- 
ditions of  circulation  and  cell  activity  might 
by  virtue  of  abundant  vitality  be  able  to 
resist  an  increase  of  irritation,  now  go  down 
before  it,  the  result  being  heteroplasia  or 
malignant  new  growth. 

If  this  explanation  be  unsatisfactory  and 
lacking  in  definiteness,  it  is  at  least  as  defi- 
nite as  anything  which  has  thus  far  been  sug- 
gested. 

TJie  Menopause  not  Responsible  for  Degen- 
erative Changes.  —  The  fact  that  malignant 
disease  develops  at  the  time  -  of  the  meno- 
pause does  not  prove  that  the  menopause  is 
responsible  for  such  development  any  more 


PRELIMINARY  CONSIDERATIONS.          27 

than  that  some  other  period  of  life  is  re- 
sponsible when  it  occurs  at  some  other 
period.  It  merely  shows  that  the  tissues 
are  then  favorable  for  such  a  development 
in  the  individuals  so  affected  or  disposed. 
Hence  we  should  banish  from  all  future  con- 
sideration the  idea  that  the  menopause  is  of 
necessity  the  time  for  such  unfavorable  pro- 


cesses.* 


PHYSICAL  CONDITION  or  WOMAN  WHEN  THE 
EIIA  OF  THE  MENOPAUSE  is  REACHED. 

Of  course  there  can  be  nothing  like  uni- 
formity in  the  physical  condition  of  woman 
as  a  wrhole  when  the  period  of  the  menopause 
is  reached,  since  the  conditions  surrounding 
them  in  the  precedent  portions  of  their  lives 
are  so  varied  and  different,  and  yet  it  has 
been  frequently  observed  that  there  are  cer- 
tain peculiar  experiences  which  are  common 

*  The  great  physiological  activity  of  the  uterus  is  assigned 
by  some  writers,  among  them  Braxton  Hicks  (Medical  Times 
and  Gazette,  1877,  i,  411),  as  a  predisposing  cause  for  malig- 
nant disease.  But  why  should  not  such  a  cause  be  equally 
potent  with  other  active  organs  ? 


28  THE  MENOPAUSE. 

to  great  numbers  of  them  which  account 
fairly  well  for  the  similarities  which  prevail 
during  the  menopause. 

The  age  at  which  the  phenomena  of  the 
menopause  occur  will  depend  upon  climate, 
family  or  race  peculiarities,  temperament,  so- 
cial surroundings,  previous  state  of  health, 
etc. 

For  the  majority  of  women  who  live  in 
temperate  climates  like  our  own,  they  are 
manifested  in  the  decade  between  the  forti- 
eth and  fiftieth  years. 

The  experiences  of  the  menopause  may 
be  classified  as— 

1.  Normal. 

2.  Moderately  troublesome. 

3.  Severe. 

4.  Serious. 

1.  Normal. — The  normal  experiences  af- 
fect a  larger  number  of  women  than  any  of 
the  others,  for  they  pertain  to  the  great  mul- 
titude who  never  consult  a  physician  about 
such  matters,  and  who  are  scarcely  conscious 
that  with  the  menopause  an  important  func- 


PRELIMINARY  CONSIDERATIONS.          29 

tion  of  life  has  vanished,  being  reminded  of 
it  chiefly  by  the  fact  that  menstruation  has 
gradually  or  suddenly  ceased.  Their  atten- 
tion may  also  be  drawn  to  the  fact  that  the 
outline  of  the  body  is  undergoing  a  change, 
straight  lines  yielding  to  curves,  and  moder- 
ate curves  to  rotundity  and  obesity. 

There  are  probably  few  women  in  this 
class  who  do  not  occasionally  experience  the 
vasomotor  crises  —  those  commonest  of  all 
concomitants  of  the  menopause,  which  will 
be  referred  to  with  the  particular  attention 
which  they  deserve  in  the  chapter  devoted 
especially  to  the  phenomena  of  the  meno- 
pause. While  they  are  frequently  a  source 
of  the  greatest  annoyance,  they  may  give  no 
more  trouble  than  a  sudden  gust  of  hot  wind 
which  vanishes  as  quickly  as  it  came  leaving 
no  trace  behind.  In  most  other  respects  this 
favored  class  experiences  no  particular  dis- 
tinction between  the  period  of  time  which 
includes  the  menopause  and  that  which  im- 
mediately precedes  or  immediately  follows  it. 
They  are  in  good  health,  and  that  means,  as 


30  THE  MENOPAUSE. 

already  stated,  unconsciousness  as  to  the  how 
and  when  of  the  performance  of  the  func- 
tions of  the  body. 

2.  Moderately    Troublesome.  —  Of    those 
with    whom    the    experiences    of  the  meno- 
pause are  moderately  troublesome,  the  gynae- 
cologist sees  many  illustrations.     The  broad 
distinction   which    may    be    made    between 
them  and  the  women  of  the  third  class  is 
that  their  troubles  are  functional  only,  while 
those  of  the  third  class  are  organic.     They 
sometimes   remind  one  of  the   peculiar  con- 
ditions  presented   by   women    during    their 
first   pregnancy.     The   symptoms  pertaining 
to  the  nervous  system  are  most  prominent — 
in  fact,  they  probably  dominate  all  others. 
As    the    circulatory   system    is    undergoing 
profound  changes  we  also  find  considerable 
visceral  disturbance.      In  general  the  distin- 
guishing characteristics  of  this  class  are  irri- 
tability of  disposition,  hysteria,  faults  of  diges- 
tion and  assimilation,  and  vasomotor  crises. 

3.  Severe.  —  In   the   third  class  of   cases 
there    are    actual   lesions   present,   some    of 


PRELIMINARY  CONSIDERATIONS.          31 

which  are  simply  accentuated  by  the  meno- 
pause, while  others  are  more  or  less  directly 
due  to  it.  The  digestive  disorders,  the  vaso- 
motor  crises  and  other  troubles  which  were 
referred  to  as  the  sufferings  of  the  second 
class,  may  also  be  present,  but  they  will  be 
overshadowed  by  the  more  serious  troubles 
of  organic  character.  Chief  among  these 
lesions  are  those  which  affect  the  womb  it- 
self, degeneration  of  the  endometrium  with 
increase  of  the  blood  tension,  resulting  in  pro- 
fuse haemorrhages.  Such  accidents  are  es- 
pecially common  in  those  uteri  which  are  the 
seat  of  myomatous  enlargement,  and  may  be 
prolonged  through  weary  years,  often  wear- 
ing the  patients  out  with  exhaustion  and 
anaemia.  This  class  also  includes  those  cases 
in  which  nervous  and  mental  troubles  are 
prone  to  culminate  in  insanity.  Heart,  kid- 
ney, and  other  visceral  diseases,  if  established 
when  the  menopause  appears,  may  take  on  a 
serious  aspect.  Any  serious  disorder  which 
occurs  during  the  period  of  the  menopause 
must  be  carefully  investigated  with  reference 


32  THE  MENOPAUSE. 

to  the  bearing  which  the  menopause  may 
have  upon  it,  though  this  is  by  no  means  an 
admission  that  serious  diseases  are  peculiarly 
prone  to  develop  at  this  time  unless  the  tend- 
ency to  them  pre-existed. 

4.  Serious. — The  serious  lesions  which  ac- 
company the  menopause,  and  which  tend  al- 
most inevitably  to  a  fatal  issue,  are  few  hi 
number,  and  the  number  of  the  cases  is  rela- 
tively small.  Cancer  does  not  develop  sim- 
ply because  menstruation  has  ceased,  or  be- 
cause the  period  of  childbearing  is  over,  but 
because  the  vitality  of  certain  tissues  is  di- 
minished and  their  ability  to  resist  irritation 
is  greatly  lessened.  With  many  women  this 
point  of  vulnerability  is  not  reached  until  the 
menopause  has  long  been  passed,  but  with 
some,  especially  with  those  who  have  borne 
many  children  or  have  experienced  much 
trouble  and  privation,  it  is  present  during 
the  decade  in  which  the  menopause  usually 
occurs,  and  in  such  cases  malignant  degenera- 
tion is  the  result. 

The   following   table   of  cases  from  the 


PRELIMINAEY  CONSIDERATIONS. 


33 


records  of  the  New  York  Skin  and  Cancer 
Hospital,  the  patients  being  taken  from  the 
humbler  and  hard-working  class  of  our  com- 
munity, shows  a  predominance  for  the  decade 
from  forty  to  fifty.  The  number  of  cases  is 
of  course  too  small  for  general  deductions. 


NATIVITY. 

Age. 

Organ. 

Social  con- 
dition. 

Children. 

Miscar- 
riages. 

Ireland  (49)  

30-40=  9 

Uter- 

Married, 

193 

21 

40-50=21 

us. 

44;  sin- 

Average 

50-60=11 

gle,  5. 

(for  mar- 

60-70= 7 

ried),  5. 

80=  1 

United       States 

20-30=  5 

Married, 

126 

40 

(36). 

30-40=  9 

34;  sin- 

Aver- 

40-50=13 

gle,  2. 

age,  4. 

50-60=  6 

60-70=  3 

Germany  (32)  .  .  . 

20-30=  1 

.... 

Married, 

97 

15 

30-40=  5 

32. 

Aver- 

40-50=13 

age,  3. 

50-60=  9 

60-70=  4 

England  (4)  

20-30=  1 

Married,  4. 

10 

0 

30-40=  1 

Aver- 

40-50= 2 

age,  2i. 

Scotland  (3)  

30-40=  1 

Married,  3. 

4 

0 

40-50=  1 

60-70=  1 

France  (2)  

20-30=  1 

Married,  2. 

2 

0 

60-70=  1 

Canada  (1)  

50-60=  1 

Married,  1. 

5 

2 

Wales  (1)  

50-60=  1 

Married,  1. 

6 

0 

Italy  (1).  . 

50-(iO=  1 

Married,  1. 

3 

0 

Poland  (1)  

30-40=  1 

Married,  1. 

1 

1 

Sweden  (1)  

60-70=  1 

Married,  1. 

2 

0 

Total  

131 

THE  MENOPAUSE. 


Of  these  one  hundred  and  thirty-one  cases 
cases  the  totals  by  decades  are  as  follows : 

DECADE.  No.  of  cases. 

20-30 8 

30-40 26 

40-50 50 

50-60 29 

60-70 17 

80 1 

131 

According  to   this   table,   therefore,   five 

O  '  ' 

thirteenths  of  these  cases  developed  cancer  in 
the  decade  during  which  the  menopause  usu- 
ally occurs.  Of  other  forms  of  cancer  in 
women  the  same  records  show  the  following : 


AGE. 

Organ. 

Social  con- 
dition. 

Chil- 
dren. 

Mis- 
car- 

Under  20,    1 

Breast, 

47 

Married,  46       145 

9 

20-30,          2 

Rectum, 

8 

Single,     10 

Aver- 

30-40,         8 

Vulva, 

5 

Not 

age,  3|. 

40-50,        18 

Clitoris, 

1 

known,  5 

50-60,         12 

Abdominal  wall, 

1 

60-70,        15 

Liver, 

1 

70-80,          5 

General  sarcoma, 

1 

Unclassified, 

2 

61 

61 

61 

Of  the  entire  number  of  cases  of  malig- 
nant disease,  one  hundred  and  ninety-two,  it 
will  be  seen  that  sixty-eight  occurred  in  the 
decade  forty  to  fifty — that  is,  slightly  more 


PRELIMINARY  CONSIDERATIONS.          35 

than  one-third  of  all  cases.  Let  us  now  con- 
sider the  distribution  of  the  various  classes  or 
types  of  women  in  accordance  with  the  ex- 
periences which  they  encounter  during  the 
menopause,  the  classification  being  the  same, 
of  course,  which  has  already  been  followed. 

1.  Normal. — All  that  tends  to  develop 
and  strengthen  the  physical  part  of  woman — 
to  render  her  insensitive  to  the  ordinary  ills 
of  life,  to  make  her  forgetful  of  self — is  fa- 
vorable to  a  normal  menopause.  Races  and 
nations  which  are  phlegmatic,  cold,  and  apa- 
thetic, women  who  are  inured  to  out-of-door 
life  and  severe  manual  labor,  savage  and  bar- 
barous women,  peasants,  Germans,  Scandina- 
vians, and  Russians,  are  apt  to  complain  little 
of  the  experiences  of  the  menopause ;  while 
the  sensitive,  passionate  nations,  like  the 
French,  Spanish,  and  Irish,  the  highly  organ- 
ized, nervous,  city-bred  women,  women  of 
fashion,  women  who  fret  and  worry,  are  apt 
to  experience  the  disagreeable  and  annoying 
features  of  the  menopause.  A  study  of  the 
sexual  peculiarities  of  the  American-Indian 


36  THE  MENOPAUSE. 

women  failed  to  reveal  any  noteworthy  ex- 
perience during  the  menopause,  and,  accord- 
ing to  Dr.  Frederic  Cook,  who  has  studied 
the  same  peculiarities  among  the  Eskimos, 
the  same  may  be  said  of  them. 

Among  the  French  and  Irish  the  troubles 
which  are  now  under  consideration  are  ex- 
ceedingly common,  which  proves  the  state- 
ment that  climate  and  race  peculiarities  have 
a  modifying  influence  upon  the  menopause. 

2.  Moderately  Troublesome. — The  number 
of  women  who  belong  to  this  class  is  very 
large.  It  includes  women  who  have  had  a 
stormy  menstrual  life,  who  have  suffered 
much  with  dysmenorrhoea,  who  have  suffered 
much  with  anaemia,  headnehe,  and  constipa- 
tion. It  also  includes  women  who  have  been 
addicted  to  venereal  excesses,  wno  have  had 
frequent  abortions,  whose  nervous  systems 

have  suffered  frequent  shocks,  who  have  had 

•r 

great  disappointments,  whose  lives  have  been 
a  constant  worry  and  unrest ;  also  women 
who  have  undergone  privation,  overwork, 
and  exposure  of  various  kinds.  Among 


PRELIMINARY  CONSIDERATIONS.          37 

them  will  be  found  many  shopwomen,  pros- 
titutes, women  of  fashion,  women  who  bring 
up  large  families  of  children  on  very  slender 
incomes,  women  who  are  hysterical  and  with 
whom  the  affairs  of  life  are  constantly  going 
wrong,  wives  of  farmers  and  mechanics  who 
are  frequently  troubled  to  make  ends  meet. 

3.  Severe. — This  class  is  smaller  than  the 
preceding  one,  but  includes,  nevertheless, 
many  well-marked  cases.  It  includes  many 
highly  wrought,  nervous  women,  and  has  as 
its  t\vo  chief  types,  as  has  already  been  re- 
marked, those  who  suffer  from  profuse  haem- 
orrhages and  those  who  develop  profound 
nervous  and  mental  troubles.  The  haemor- 
rhages may  be  due  simply  to  a  diseased  and 
degenerating  endometrium,  or  to  the  presence 
of  fibroid  tumors  within  the  uterus.  If  from 
the  latter,  the  phenomena  of  the  menopause, 
including  the  haemorrhages,  may  be  pro- 
longed through  many  years,  atrophy  finally 
taking  place  if  the  woman  has  sufficient  vital- 
ity to  endure  the  prolonged  drain  -upon  it. 
With  the  women  of  the  other  type  the  con- 


38  THE  MENOPAUSE. 

stant  irritation  of  the  nervous  system  finally 
culminates  in  insanity,  melancholia  or  mania 
appearing  according  to  the  temperament  and 
disposition  of  the  individual.  Insanity  of 
this  form  may  be  permanent,  because  it  may 
be  dependent  upon  degenerative  conditions 
of  the  nerve  substance.  Of  course  there  are 
many  cases  in  which  ultimate  recovery  is 
possible  and  does  occur.  Women  who  are 
already  the  subjects  of  visceral  disease  of  the 
heart,  liver,  kidneys,  lungs,  stomach,  etc., 
when  the  menopause  arrives  may  have  their 
symptoms  intensified  by  the  additional  dis- 
turbance which  a  troublesome  menopause 
brings. 

4.  Serious. — -This  class  includes  those 
who  are  already  foredoomed  by  an  existing 
or  impending  serious  condition,  to  which  the 
processes  which  accompany  the  menopause 
can  add,  or  from  which  they  can  take  away, 
but  little.  The  haemorrhage  and  destruction 
of  tissue  and  sepsis  in  such  cases  are  not  es- 
sentially due  to  the  menopause,  for  precisely 
the  same  symptoms  occur  when  the  same  dis- 


PRELIMINARY  CONSIDERATIONS.          39 

ease  happens  early  in  life,  or  long  after  the 
menopause  has  ended.  The  cause  must  be 
sought  elsewhere,  and,  when  it  is  found,  it 
will  be  found  to  be  the  same  for  all  ages  and 

periods  of  life. 

ADDENDA. 

GUY.  On  the  First  and  Last  Appearance  of  the 
Menses.  Medical  Times,  London,  1845,  xii,  363. 

SMITH.  The  Climacteric  Disease,  a  Paroxysmal 
Affection  occurring  at  the  Decline  of  the  Catamenia. 
London  Journal  of  Medicine,  1849,  i,  601. 

FELTY.  The  Menopause,  its  Relation  to  Disease. 
Kansas  Medical  Journal,  1891,  iii,  85. 

THOMAS.  The  Menopause,  or  Change  of  Life. 
Annals  of  Gynaecology  and  Paediatry,  Philadelphia, 
1890,  iv,  449. 

MILES.  On  the  Climacteric  Period,  etc.  Medical 
Times  and  Hospital  Gazette,  1894,  xxii,  119. 

JOHNSTONE.  The  Menopause.  New  York  Jour- 
nal of  Gynaecology  and  Obstetrics,  1894,  iv,  393. 

MUXDE.  The  Menopause.  International  Clinics, 
1894,  4s,  i,  283. 

KOBINSON.  The  Menopause.  Journal  of  the 
American  Medical  Association,  1894,  xxiii,  345. 

O'CONNOR.  Observations  on  Climacteric  Disease. 
Dublin  Journal  of  the  Medical  Sciences,  1875,  Ix,  78. 

WILLIAMS.  Climacteric  Disease.  Boston  Medical 
and  Surgical  Journal,  1855,  Iii,  69. 

DE  SERE.  Sexual  Activity  and  the  Critical  Period 
in  Man  and  Woman.  Wood's  Medical  and  Surgical 
Monographs,  iii. 


40  THE  MENOPAUSE. 

TARNOWSKI.  Etude  anthropometrique  sur  les 
Prostituees  et  les  Voleuses.  Paris,  Aux  Bureaux  des 
Progres  medicals,  1889  ;  also  Medical  Record,  August 
9,  1890,  p.  15.^ 

BARIE.     Etude  sur  la  Menopause,  Paris,  1877. 

TILT.  The  Right  Understanding  of  the  Meno- 
pause. British  Medical  Journal,  1870,  ii,  435. 

DE  REDONDO.  No  edad  critica.  Fraternidad 
medica,  Valladolid,  ii,  640. 

BARON.     De  la  Menopause,  Paris,  1851. 

NETTLER.  The  Menopause.  Medical  Register, 
1887,  ii,  323. 

WYMAN.  The  Menopause.  Michigan  Medical 
News,  1882,  v,  313. 

GOODELL.  Transactions  of  the  Pennsylvania  Med- 
ical Society,  1881,  xiii,  Part  I,  638. 

KENNEDY.  Observations  on  Climacteric  Disease. 
Dublin  Journal  of  the  Medical  Sciences,  1844,  xxv, 
245. 

RACIBORSKI.  De  la  Puberte  et  de  1'Age  critique 
chez  la  Femme  et  de  la  Ponte  periodique  chez  la 
Femme  et  les  Mammiferes,  Paris,  1844. 

TILT.  On  Uterine  and  Ovarian  Inflammation,  and 
on  the  Physiology  and  Diseases  of  Menstruation.  Lon- 
don, 1862. 

STEPHENSON.  On  the  Menstrual  Wave.  Ameri- 
can Journal  of  Obstetrics,  1882,  xv. 

REINL.  Die  Wellenbewegung  der  Lebensprocesse 
des  Weibes.  Volkmann's  Vortrage,  No.  243. 

JENKS.  Concerning  Menstruation  among  the  An- 
cients. Transactions  of  the  American  Gynaecological 
Society,  vi,  373. 


CHAPTER  II. 

CONSIDERATIONS    CONCERNING    THE    ORGANS    OF 

THE       GENITAL       APPARATUS ANATOMICAL 

CHANGES    EFFECTED    BY    THE    MENOPAUSE. 

Menopause  indicates  Completion  of  Fruit- 
ful Period. — The  menopause  is  the  signal 
that  fruition  is  ended.  In  the  vegetable 
world  the  period  of  fruition  is  followed  by 
decided  and  perceptible  structural  changes. 
Foliage  assumes  its  most  brilliant  colors, 
then  falls  and  withers.  Analogous  changes 
occur  in  women  with  the  period  of  the  meno- 
pause, and  subsequently  the  hair  whitens, 
the  figure  becomes  rotund,  but  in  due  course 
of  time  withering  and  wrinkles  follow.  In 
the  reproductive  organs  the  advent  of  the 
menopause  means  the  beginning  of  senility, 
and  that  signifies  atrophy  and  degeneration 
of  structure,  and  sometimes,  though  not  ne- 
cessarily, the  institution  of  morbid  processes. 

41 


42  THE  MENOPAUSE. 

The  subject  will  be  studied  from  the  follow- 
ing standpoints : 

Classification. — 1.    Anatomical      changes 
which  are  the  result  of  the  menopause. 

2.  Anatomical  changes  which  produce  the 
menopause. 

3.  Anatomical  changes  which  are  coinci- 
dental with  the  menopause,  but  which  are 
not  usually  its  cause  or  caused  by  it. 

Necessarily,  the  organs  of  the  reproduc- 
tive apparatus  must  be  considered  in  detail. 

ANATOMICAL  CHANGES  IN  THE  OVARIES. 
The  ovaries  are,  to  a  very  decided  degree, 
the  center  of  the  reproductive  apparatus  in 
women — the  sine  qua  non  in  the  continua- 
tion of  species.  Their  function  is  ovulation 
— the  development  and  extrusion  of  ova — 
and  their  intimate  nervous  relations  with 
other  viscera  doubtless  explain  the  many 
curious  phenomena  which  are  observable  in 
connection  with  menstruation  and  its  discon- 
tinuance. 

Ovulation  may  continue  after  the  menses 


ANATOMICAL  CHANGES.  43 

Lave  ceased.  The  proof  of  this  is  that  preg- 
nancy sometimes  takes  place  after  the  meno- 
pause has  occurred.* 

After  ovulation  ceases  the  work  of  the 
ovaries  is  accomplished,  and  unless  some 
morbid  change  takes  place  in  them,  they  be- 
come shriveled  and  atrophied.  The  anatom- 
ical changes  in  the  ovaries  during  and  after 
the  menopause  have  been  very  clearly  and 
satisfactorily  described  in  a  paper  published 
by  the  late  Prof.  J.  C.  Dalton  in  the  Trans- 
actions of  the  American  Gynaecological  So- 
ciety, vol.  ii,  1877.f  From  that  report  the 
following  cases,  in  a  condensed  form,  have 
been  taken : 


*  Puech,  Renaudier,  Kisch,  Krieger,  and  Deshayes  have 
all  reported  cases  of  this  character.  A  number  of  such  cases 
have  been  brought  to  the  attention  of  the  author.  Among 
them  was  one  who  was  the  mother  of  a  medical  colleague, 
who  gave  birth  to  a  son  several  years  after  she  had  passed 
the  menopause.  Another  was  a  case  in  which  a  child  was 
born  fourteen  years  after  the  cessation  of  menstruation. 

Piron  (Lancet,  ii,  1862,  p.  27)  observed  a  regular  monthly 
flow  for  six  months  in  a  woman  seventy-two  years  of  age. 
She  then  became  pregnant,  but  aborted  at  the  second  month, 
the  foetus  being  recovered. 

t  Report  on  the  Corpus  Luteum. 


44  THE  MENOPAUSE. 

I.  Married    woman,    forty-eight   years   of 
age,  mother  of  seven  children,  died  one  day 
after  the  end  of  a  menstrual  period.     Men- 
struation had  always  been  regular  and  pain- 
less.    One  of  the  ovaiies  contained  a  super- 
ficial Graafian  follicle  considerably  enlarged 
and  filled  with  a  fresh,  dark-red  blood  clot. 
Both  ovaries  exhibited  alteration  of  structure 
corresponding  with  the  patient's  age  and  the 
near    approach    of    the    menopause.      There 
were  few  healthy,  active,  Graafian  follicles ; 
some  were  morbidly  distended,  others  were 
shriveled.     Each  ovary  contained  two  unrup- 
tured  follicles  which  had  undergone  chronic 
degeneration,  the  wralls  being  thickened  and 
the  contents  absorbed,  forming  false  corpora 
lutea. 

II.  A  widow,  thirty-three  years  of   age, 
who   died   from   phthisis   pulmonalis.      Last 
pregnancy  at  twenty  ;  menstruation  irregular 
for  a  year;  last  period  six  months  prior  to 
death.      Ovaries  small,  surrounded  with  old 
adhesions  ;     albuginea    white    and    opaque. 
Small  rounded  projection   near   one   end  of 


ANATOMICAL  CHANGES.  46 

right  ovary,  brownish  in  color.  It  contained 
an  ovoidal  body  three  to  four  millimeters  in 
its  long  diameter,  having  the  structure  of  a 
retrograde  corpus  luteum  of  menstruation. 
Its  wall  was  convoluted  half  a  millimeter  in 
thickness,  its  color  white ;  it  contained 
brownish  gelatinous  material.  A  similar 
smaller  body  was  at  the  opposite  end  of 
the  same  ovary.  The  left  ovary  contained 
a  very  thin,  shriveled  white-walled  sac,  con- 
nected with  a  superficial  cicatrix  and  contain- 
ing black  coloring  matter.  In  both  ovaries 
there  were  collapsed,  empty,  degenerate 
Graafian  follicles,  not  connected  with  the 
surface,  but  scattered  through  the  tissue  of 
the  organs. 

III.  Prostitute,  thirty  years  of  age,  death 
from  waxy  degeneration  of  the  kidneys  and 
disease  of  the  liver.  Menstruation  had  ceased 
eight  months  prior  to  death.  Both  ovaries 
enveloped  in  old  adhesions,  their  substance 
being  condensed  and  atrophied.  In  one 
there  were  a  few  brownish  or  yellowish 
streaks  without  definite  structure.  Neither 


4:6  THE  MENOPAUSE. 

contained  healthy  Graafian   follicles   or  cor- 
pora lutea. 

IV.  Prostitute,  twenty-one  years  of  age, 
death   from   cardiac  disease  and  pulmonary 
oedema ;  last  menstruation  ten  months  prior 
to  death.     Ovaries  small,  but  free  from  ad- 
hesions,   their  tissue  abnormally  dense   and 
containing  a  few  small  Graafian  follicles  but 
no  corpora  lutea. 

V.  Woman,  forty-three  years  of  age,  who 
had  had  one  child  twenty-one  years  previ- 
ously.   Death  from  cerebral  meningitis.    Last 
menstruation  a  year  prior  to  death.     Ovaries 
small   and   loose  in  texture,   containing  col- 
lapsed, empty,  degenerate  Graafian  follicles, 
with    slightly   thickened    walls,    which    had 
long   been   inactive.     In   the   ovarian  tissue 
were   a   few   small   blackish   stains   without 
definite  structure.     No  normal  Graafian  folli- 
cles nor  corpora  lutea. 

VI.  Woman,  fifty-five  years  of  age,  multi- 
para,  death   from   abscess   of  the  liver  and 
pneumonia.      Last    menstruation    six    years 
prior   to   death.      One    ovary   weighed    one 


ANATOMICAL  CHANGES.  4? 

gramme,  the  other  less  than  one  gramme  and 
a  half.  The  external  surface  was  opaque,  yel- 
lowish white,  with  numerous  depressed  curvi- 
linear cicatrices.  Internally  the  color  was  a 
pale  red,  the  consistency  firm,  and  there  were 
neither  Graafian  follicles  nor  corpora  lutea. 
The  entire  substance  consisted  of  a  moder- 
ately vascular  connective  tissue. 

VII.  Woman,  forty-five  years  of  age,  the 
mother  of  fourteen  children.  Death  from 
rupture  of  thoracic  aneurism.  Menstruated 
once  during  last  year  of  life.  Ovaries  under 
the  average  size,  white  and  opaque  exter- 
nally, with  depressed,  intercommunicating 
cicatrices,  beneath  which  were  small  colored 
clots,  with  and  without  membranous  walls, 
flattened  from  within  outward.  The  ovaries 
contained  four  or  five  small  Graafian  follicles, 
visible  externally ;  also  two  large  ones  be- 
neath the  albuginea,  which  had  collapsed 
after  their  contents  had  been  reabsorbed. 
Their  walls  were  friable.  Several  other  folli- 
cles had  thickened  walls,  and  were  collapsed 
and  empty.  There  were  no  corpora  lutea. 


VIII.  Woman,  seventy  years  of  age,  mul- 
tipara.  Ovaries  half  the  normal  size.  They 
were  lobular  internally,  and  contained  col- 
lapsed Graafian  follicles  in  the  form  of  closed 
empty  sacs  (saccular  degeneration),  with 
firm,  pale,  thickened,  and  puckered  walls. 
The  sacs  were  enucleated,  and  the  interspaces 
showed  loose  red  connective  tissue.  No 
healthy  Graafian  follicles  nor  other  structural 
formations. 

Analysis  of  the  Foregoing  Cases. — An 
analysis  of  these  most  interesting  cases  gives 
the  following  results,  which  may  be  consid- 
ered an  ensemble  of  the  ovarian  changes 
which  the  menopause  implies :  In  women 
who  reach  the  menopause  prematurely  from 
wasting  diseases,  such  as  pulmonary  phthisis 
(case  II),  from  amyloid  disease  (III),  from 
cardiac  disease  (IV),  the  ovaries  may  be  re- 
duced to  half  the  size  they  usually  reach 
during  functional  activity.  They  may  be 
surrounded  by  evidences  of  previous  inflam- 
matory condition,  or  such  evidences  may  be 
wanting.  They  may  be  converted  into 


ANATOMICAL  CHANGES.  49 

masses  consisting  chiefly  of  connective  tissue, 
or  there  may  still  be  "more  or  less  ovarian 
stroma  remaining,  with  more  or  fewer  Graaf- 
ian  follicles  and  corpora  lutea  in  varying 
stages  of  degeneration,  according  to  the  near- 
ness or  remoteness  of  the  time  when  func- 
tional activity  ceased,  or  the  degree  of  malnu- 
trition of  the  body  in  general,  and  the  pelvic 
organs  in  particular.  It  is  not  improbable 
that  similar  changes  would  be  found  in  the 
ovaries  of  those  who  reach  the  menopause 
prematurely  from  causes  other  than  wasting 
diseases,  as  from  great  obesity,  frequent  preg- 
nancies in  quick  succession,  and  the  trau- 
matic conditions. 

2.  In  women  who  reach  the  menopause 
at  the  normal  period  the  ovaries,  if  examined 
while  the  change  is  in  progress  or  soon  after 
it  is  completed,  may  show  little  reduction  in 
size.  There  may  be  evidences  of  pre-existent 
disease  in  the  form  of  bands  and  adhesions. 
Some  ovarian  stroma  may  still  be  present, 
but  there  will  be  an  abundant  formation  of 
connective  tissue.  The  Graafian  follicles  and 

5 


50  THE  MENOPAUSE. 

corpora  lutea  will,  as  a  rule,  be  fewer  and 
less  distinct  than  in  ovaries  which  are  in 
active  functional  condition. 

3.  In  women  in  whom  the  menopause  has 
long  been  passed,  the  ovaries  may  be  shriv- 
eled to  a  quarter  or  even  a  fifth  of  their 
average  size  (Dalton).  They  will  be  com- 
posed mostly  of  connective  tissue,  but  the 
scars  of  corpora  lutea  may  usually  be  found 
upon  or  within  them,  and  there  may  be  sac- 
cular  degeneration  of  Graafian  follicles  which 
have  long  since  become  inactive,  the  latter 
representing  a  peculiar  phase  of  atrophy 
which  may  or  may  not  be  of  any  pathological 
significance. 

Kisch,  in  the  work  to  which  reference  has 
been  made,  coincides  with  the  statements 
which  were  made  by  Dalton.  He  also  ob- 
served that  the  connective-tissue  changes  in 
ovaries  during  and  after  the  menopause  were 
from  the  periphery  to  the  center,  the  epi- 
thelial elements  being  thus  gradually  com- 
pressed. In  the  Graafian  follicles  the  first 
retrograde  change  is  fatty  degeneration  with 


ANATOMICAL  CHANGES.  51 

the  formation  of  a  granular  detritus.  While 
the  membrana  propria  of  the  follicle  is  still 
unchanged,  quantities  of  round  fat  drops  may 
be  found  in  the  granulation  layer,  together 
with  unchanged  cells  of  that  layer,  and  also 
ovum  cells.  These  constantly  increase,  so 
that  finally  "none  of  the  cell  contents  remain, 
the  follicle  containing  only  granular  matter 
and  fluid.  The  tunica  propria  then  becomes 
oval,  long,  or  angular.  In  a  subsequent 
stage  the  Graafian  follicle  becomes  a  bladder- 
like  body,  oblong,  with  many  folds,  continu- 
ing to  contract,  and  being  filled  with  a  trans- 
parent fluid,  round  cells,  and  an  intercellular 
substance.  It  is  finally  converted  into  a 
long,  oval,  fibroid  mass,  which  is  connected 
with  the  surrounding  stroma  by  thick  fibrils, 
and  the  cavity  is  reduced  to  a  bare  cleft 
without  appreciable  contents.  As  the  tunica 
albuginea  thickens,  the  opening  of  matured 
follicles  is  prevented,  and  Kisch  believes  that 
this  causes  the  irregularity  and  difficulty  of 
menstruation  at  this  period  with  pain,  hys- 
teria, etc. 


52  THE  MENOPAUSE. 

Among  the  other  writers  who  may  be 
profitably  consulted  with  reference  to  the 
anatomical  changes  produced  by  the  meno- 
pause are  Borner,  Puech,  Kiwisch,  Waldeyer, 
Hegar,  and  Strojnowski. 

Puech  found  the  ovaries  nearly  normal  in 
size  in  a  woman  who  had  passed  the  meno- 
pause three  years  previous  to  the  operation 
in  which  he  removed  them,  and  Kiwisch  and 
Waldeyer  also  describe  the  atrophic  process 
as  a  very  slow  one. 

Hegar  and  Krieger  assert,  in  addition, 
that  atrophy  of  the  ovaries  precedes  atrophy 
of  the  uterus,  owing  to  the  arrest  of  the  re- 
productive power  before  complete  cessation 
of  the  menses.  Of  course  this  process  is  sub- 
ject to  exceptions. 

Strojnowski  reports  eleven  cases  in  which 
atrophy  of  the  ovaries  was  due  to  diabetes.* 

We  may  therefore  assert  that  the  anatom- 
ical changes  in  the  ovaries  at  and  after  the 
menopause  are  atrophic  in  character,  and 
usually  take  place  slowly.  The  epithelial 

*  See  Satellite,  January,  1392,  p.  93. 


ANATOMICAL  CHANGES.  53 

elements  gradually  give  place  to  connective 
tissue,  the  Graafian  follicles  and  corpora  lutea 
are  completely  destroyed,  or  the  only  evi- 
dence that  they  ever  existed  consists  in  a  few 
scars  upon  the  tunica  albuginea,  which  be- 
comes thick  and  shriveled. 

The  nerve  and  vascular  supply  is  dimin- 
ished or  cut  off,  and  the  same  is  true  concern- 
ing the  lymphatic  supply.  With  regard  to 
the  latter,  His  and  Slavjansky  assert  its 
abundant  distribution  to  the  ovaries,  while 
Exner  and  Buckel  deny  it.* 

Thus  the  imperious  influence  of  these  or- 
gans upon  the  body  at  large  is  brought  to  an 
end. 

ANATOMICAL  CHANGES  .IN  THE  UTEEUS. 
Changes  in  the  uterus  are  also  induced 

o 

by  the  menopause,  and  it  will  be  convenient 
again  to  invoke  the  work  of  Dalton  already 
impressed  into  service,  for  testimony  upon 
this  portion  of  the  subject.  The  numbers  of 


*  Sec  article  Ovary  in  Reference  Handbook  of  the  Medical 
Sciences. 


5±  THE  MENOPAUSE. 

the  cases  are  the  same  as  were  used  in  the 
remarks  concerning  the  ovaries. 

II.  Widow,  thirty-three  years  of  age,  who 
died  of  pulmonary  phthisis.     The  uterus  was 
empty  and  normal  in  appearance.     Its   mu- 
cous membrane  was  pale  throughout. 

III.  Prostitute,  thirty  years  of  age,  who 
died  of  waxy  degeneration  of  the  kidneys  and 
disease  of  the  liver.     Uterus  empty  and  of 
small     size,    mucous     membrane    pale    and 
smooth. 

IV.  Prostitute,  twenty-one   years  of  age, 
who  died  of  cardiac  disease  and  pulmonary 
oedema.     Uterus  small  and  empty.     Mucous 
membrane  of  cervix  pale;  that  of  the  body 
very  thin,  but  reddened  with  an  uniform  fine 
vascularity. 

V.  Woman,  forty-three  years  of  age,  who 
died     from     cerebral     meningitis.       Uterus 
empty,   of  medium  size,   and  normal  in   ap- 
pearance, with  the  exception  of  a  constriction 
at  the  os  internum.     The  mucous  membrane 
was  smooth  and  pale,  marked  only  with   a 
slight  arborization  of  fine  vessels. 


ANATOMICAL  CHANGES.  55 

VI.  Woman,  fifty-five  years  of  age,  who 
died  from  abscess  of  the  liver  and  pneumonia. 
Uterus  small  and  empty,  and  mucous  mem- 
brane pale  throughout.     It  contained  a  small 
fibrous  tumor  in  its  posterior  wall. 

VII.  Woman,  forty-five  years  of  age,  who 
died  from  thoracic  aneurism.      Uterus  large, 
but  empty,  and  normal  in  appearance.     Mu- 
cous membrane  pale  except  for  a  rosy  tint 
near  the  fundus. 

VIII.  Woman,    seventy    years    of    age. 
Uterus  healthy  except   for   a   small  fibrous 
tumor   in   one  of  its  walls;  also  thickening 
and  reddening  of  the  adjacent  mucous  mem- 
brane. 

The  findings  concerning  the  uterus  in  the 
foregoing  cases  are  meaner,  but  show  suffi- 

o         o  o      / 

ciently  that  with  the  menopause  comes  im- 
paired nutrition  and  reduction  in  volume,  ex- 
cept in  cases  in  which  the  uterus  is  the  seat 
of  a  neoplasm,  when  it  may  retain  its  large 
size  indefinitely. 

The  author  is  prepared  to  verify  the  state- 
ments of  Dalton  upon  the  basis  of  numerous 


56  THE  MENOPAUSE. 

operations  upon  old  women  from  whom,  for 
one  cause  and  another,  the  uterus  has  been 
removed.  The  fact  that  the  endometrial  mu- 
cous membrane  was  not  uniformly  anaemic  in 
Dalton's  cases,  as  well  as  the  condition  of  the 
ovaries  in  these  cases,  confirms  Hegar's  state- 
ment that  the  ovaries  atrophy  prior  to  the 
atrophy  of  the  uterus.  Indeed,  many  ob- 
servers have  noticed  that  in  the  early  stages 
of  the  menopause  congestion  of  the  uterine 
mucous  membrane  and  enlargement  of  the 
organ  are  of  common  occurrence. 

Thomas  asserts  *  that  the  contraction  and 
atrophy  of  the  cervix  take  place  more  rapidly 
than  do  the  similar  processes  in  the  corpus 
uteri.  Such  a  process  may  be  followed  by 
atresia  and  stenosis  of  the  cervical  canal  while 
the  glands  of  the  endometrium  are  still  pour- 
ing out  their  secretion.  This  may  result  in 
retention  of  secretions,  in  degeneration,  in 
haemorrhage,  etc.  Such  an  explanation  will 
fit  a  certain  number  of  cases,  but  not  all ;  in- 
deed the  author  believes  that  in  many  cases 

*  Annals  of  Gynaecology  and  Paediatry,  1891,  iv,  p.  449. 


ANATOMICAL  CHANGES.  57 

degeneration  of  the  cervix  and  of  the  corpus 
proceed  pari  passu.  In  married  women 
with  whom  sexual  intercourse  is  of  frequent 
occurrence  it  is  not  unlikely  that  the  corpus 
atrophies  more  rapidly  than  the  cervix. 

Kisch  *  observed  that  the  vaginal  portion 
of  the  cervix  was  usually  soft  during  the 
menopause,  eroded,  and  easily  provoked  to 
haemorrhage ;  also  that  the  entire  organ  was 
rather  soft  and  relaxed  with  evidences  of 
stasis  in  the  vena  cava  ascendens,  the  pelvic 
vessels,  and  those  of  the  uterine  walls  and 
mucous  membrane.  He  had  also  not  infre- 
quently observed  hydrometra  as  the  result  of 
stenosis  of  the  cervical  canal  and  the  reten- 
tion of  secretions ;  also  prolapsus  and  dis- 
placements of  the  uterus,  of  which  the  latter 
conditions  may  be  less  disturbing  during  the 
menopause  than  during  the  childbearing 
period. 

With  respect  to  the  foregoing  opinions  of 
Kisch,  the  author  begs  leave  to  say  that  in 
his  experience  prolapsus  uteri  is  not  a  result 

*  Op.  cit. 


58  THE  MENOPAUSE. 

of  the  menopause ;  in  fact,  so  far  as  the  uterus 
itself  is  concerned,  when  it  is  not  the  seat  of 
an  inflammatory  or  neoplastic  process,  the 
atrophy  which  it  undergoes,  with  diminution 
in  size  and  weight,  would  of  course  tend  to 
check  rather  than  to  exaggerate  a  condition 
of  prolapse. 

Klob,  whose  work  on  the  anatomy  and 
pathology  of  the  uterus  performed  valuable 
pioneer  service,  *  regarded  the  changes  in- 
duced in  the  organ  by  the  menopause  as  an- 
alogous with  those  in  the  ovaries,  the  muscu- 
lar fibers,  especially  those  which  are  in  the 
fundus  and  corpus  being  finally  reduced  to 
connective  tissue. 

Classification  of  Uteri. — The  author's  in- 
vestigation of  a  large  number  of  cases  in 
which  the  uterus  was  undergoing  the 
changes  of  the  menopause,  would  lead  him 
to  divide  such  cases  into  the  following 
classes  : 

1.  Those  in  which  the  menopause  is  pro- 
gressing. 

*  See  translation  by  Kammerer  and  Dawson,  1868,  p.  222. 


ANATOMICAL  CHANGES.  59 

2.  Those  in  which  it  has  taken  place  at 
the  customary  time  as  a  natural  process. 

3.  Those  in  which  it  has  taken  place  pre- 
maturely. 

4.  Those  in  which  the  interval  of  time 
which  has  elapsed  since  it  occurred  has  been 
very  long. 

In  the  first  class  there  is  either  no  per- 
ceptible anatomical  change,  or  there  is  the 
congestion,  the  hypertrophy,  the  granulations 
of  the  endometrium,  with  enlargement  of  the 
organ  and  the  occasional  profuse  haemor- 
rhages which  are  incidental.  Frequently 
there  is  also  excessive  discharge  from  the 
overstimulated  uterine  glands,  but  seldom  an 
inflammatory  process. 

In  the  second  class,  two  years  or  more 
having  intervened  since  the  last  menstruation, 
atrophy  of  the  tissues  of  the  uterus  is  well 
marked.  The  mucous  membrane  is  pale  and 
less  sensitive  than  formerly,  except  at  the 
fundus,  and  sometimes  at  the  os  internum, 
where  sensitiveness  continues  acute.  The 
entire  organ  is  reduced  in  size,  the  reduction 


60  THE  MENOPAUSE. 

in  the  portio  vaginalis  being  particularly 
marked.  Glandular  discharge  is  usually  in- 
significant, the  atrophic  process  having  now 
involved  the  glands  as  well  as  the  other  tis- 
sues. 

In  the  third  class  the  changes  are  not  ma- 
terially different  from  those  of  the  second. 
It  has  seemed  to  the  author  that  the  entire 
process  of  atrophy  moved  on  more  rapidly 
when  the  menopause  was  induced  abruptly 
by  the  removal  of  the  ovaries  than  under 
natural  conditions,  more  rapidly  also  than  in 
those  cases  in  which  obesity  or  excessive 
childbearing  had  been  the  cause. 

In  the  obesity  cases  there  is  more  or  less 
deposit  or  infiltration  of  fat,  or  fatty  degener- 
ation of  the  muscular  tissue  of  the  uterus,  so 
that  it  may  seem  even  larger  than  under  nor- 
mal conditions. 

In  the  fourth  class  the  uterus  is,  as  a  rule, 
insignificant  in  size,  the  portio  vaginalis  may 
be  shriveled  to  a  mere  buttonlike  projection 
or  may  be  reduced  to  a  mere  slit  in  the  an- 
terior vaginal  wall.  The  corpus  also  may  be 


ANATOMICAL  CHANGES.  61 

no  larger  than  a  pigeon's  egg.  In  a  few 
cases  the  author  has  been  unable  to  find  any- 
thing that  could  suggest  the  former  existence 
of  a  parous  organ,  so  completely  had  atrophy 
performed  its  work.  On  the  other  hand,  even 
in  extreme  age  the  organ  has  been  found 
several  inches  in  length,  its  nutrition  being 
continued  by  the  neoplasms  within  its  struc- 
ture. A  condition  of  extension,  and  even 
hypertrophy,  may  also  accompany  prolapsus 
when  the  vagina  and  other  natural  supports 
are  no  longer  able  to  hold  it  in  its  proper 
place.  Posterior  displacements  of  the  uterus 
do  not  retard  the  atrophic  process  unless 
the  circulatory  disturbance  is  considerable. 
Extensive  venous  stasis  means  increased 
nutrition.  In  general,  with  virgins  and 
widows  who  are  continent,  uterine  atrophy 
is  more  complete  and  more  prompt  than 
with  married  women.  Of  glandular  dis- 
charge from  the  uterus  there  is  usually 
none,  the  glands  having  become  quite  func- 
tionless  or  perhaps  having  disappeared  en- 
tirely. 


62  THE  MENOPAUSE. 

Anatomical  Changes  in  the  Fallopian 
Tubes,  Vagina,  and  Clitoris. — The  uterus 
and  ovaries  are  not  the  only  organs  in  which 
the  degenerative  changes  which  have  been 
depicted  occur.  Such  changes  will  also  be 
observed  in  the  other  members  of  the  genital 
apparatus — nay  more,  in  portions  of  the  body 
with  which  the  genital  apparatus  has  no  im- 
mediate association. 

The  Fallopian  tubes  shrink  and  shorten, 
the  fimbriated  ends  gradually  disappear,  and 
the  organs  are  reduced  to  mere  hardened 
strings  of  connective  tissue,  deficient  in  vascu- 
larity,  functionless.  The  preliminary  changes 
in  the  vagina  may  be  hyperaemia,  increased 
glandular  secretion  and  increased  sensitive- 
ness. The  congestion  may  be  an  element  in 
that  general  congestion  of  the  pelvic  tissues 
which  no  longer  has  expression  and  outlet  in 
the  customary  monthly  flow.  Hypersemia  is 
succeeded  by  contraction  of  the  vessels  and 
anaemia ;  the  mucous  membrane  loses  its  rugae, 
becomes  smooth  and  pale ;  the  vaginal  tube  is 
shortened,  the  vault  contracted,  and  bands  of 


ANATOMICAL  CHANGES.  63 

connective  tissue  may  be  stretched  across  the 
latter  or  adhesions  formed  in  other  portions 
of  the  vaginal  tube.  The  introitus  undergoes 
narrowing,  especially  in  virgins  and  nulli- 
parse ;  it  is  sometimes  so  narrow  that  it  will 
scarcely  admit  the  examining  finger,  while  the 
tube  is  shortened  to  a  length  of  not  more  than 
an  inch  or  two.  The  vaginal  glands  often  se- 
crete an  acrid  muco-purulent  substance  which 
causes  the  most  intense  pruritus  of  the  tissues 
which  may  be  soiled  by  it.  Not  infrequently 
the  relaxation  of  the  vaginal  tissues  is  fol- 
lowed by  prolapse  of  one  or  both  vaginal 
walls,  and  the  uterus,  bladder,  or  rectum,  or 
all  together,  may  be  included  in  the  descent. 
This  happens  especially  with  women  in 
whom  the  vagina  is  voluminous,  who  have 
borne  many  children,  and  with  whom  the 
structures  which  usually  act  as  supports  and 
barriers  for  these  organs  have  weakened  or 
given  way.  Atrophy  of  the  clitoris  and  ex- 
ternal genitals  also  occurs,  the  hair  upon  the 
labia  becomes  thin  and  scraggy,  the  cushion 
of  fat  in  the  labia  majora  and  mons  veneris 


64  THE  MENOPAUSE. 

shrinks,  the  vulva  becomes  wrinkled,  the 
labia  minora  contract,  and  in  some  cases  dis- 
appear entirely.  The  clitoris  also  ceases  to 
become  sensitive  or  congested,  and  returns 
to  a  rudimentary,  permanently  inactive  con- 
dition. 

Coitus  with  those  who  have  undergone 
these  senile  changes  is  not  only  very  painful 
(to  the  women)  in  many  cases,  but  may  be 
followed  by  certain  neuroses  and  psychoses 
to  which  women  at  this  period  of  life  are 
very  susceptible.* 

Anatomical  Changes  in  the  Mammary 
Glands. — The  mammary  glands  share  in  the 
atrophic  process  of  the  remainder  of  the  geni- 
tal apparatus,  they  and  the  milk  ducts  shrink- 
ing to  rudimentary  conditions.  Hardening 
of  ducts  and  glands  often  leads  to  the  sus- 
picion of  disease,  and  many  breasts  have 

*  In  a  case  which  occurred  in  the  author's  practice  a 
woman  of  forty-five,  who  passed  the  menopause  at  thirty- 
nine,  suffered  with  mental  disturbance  which  was  most 
marked  after  the  sexual  approaches  of  a  brutal  husband.  He 
succeeded  in  having  her  committed  to  a  lunatic  asylum,  where 
she  soon  recovered,  the  cause  of  her  trouble  having  been  re- 
moved. 


ANATOMICAL  CHANGES.  65 

fallen  a  sacrifice  to  the  knife  when  the  cause 
of  the  trouble  was  purely  a  physiological  one. 
This  being  a  matter  of  actual  knowledge  and 
experience,  the  author  would  insist  upon  the 
necessity  of  differentiating  a  physiological 
from  a  diseased  condition.  The  fat  of  the 
breasts  is,  in  most  cases,  gradually  absorbed, 
the  nipple  shrinks,  and  the  breasts  become 
wrinkled,  skinny,  and  no  longer  objects  of 
beauty  and  symmetry.  Not  a  few  women, 
however,  retain  the  beauty  of  outline  of  these 
structures  to  extreme  age,  though  the  general 
appearance  is  not  and  can  not  be  that  of  the 
breasts  of  the  presenile  period.  Previous  to 
the  occurrence  of  atrophy  there  may  also  be 
a  period  of  congestion  and  irritation  in  the 
breasts.  Tilt  has  observed  such  a  condition 
fourteen  times  in  the  five  hundred  cases  of 
menopause  which  he  has  tabulated  and  ana- 
lyzed. In  the  cases  in  question  the  breasts 
were  swollen  and  painful,  the  nipples  wrere 
sore,  and  occasionally  they  exuded  a  milky 
or  glutinous  fluid.  This  condition  of  conges- 
tion not  infrequently  gives  rise  to  the  sus- 


66  THE  MENOPAUSE. 

picion  of  pregnancy,  at  least  in  the  mind  of 
the  individual  who  suffers.  It  is  always  a 
condition  which  calls  for  careful  inspection 
and  treatment. 

Changes  in  other  Structures  of  the  Body. 
— It  may  not  be  amiss  to  note  that  not  in 
the  generative  organs  alone  do  degenerative 
changes  take  place  at  the  period  of  the  meno- 
pause. The  hair  changes  its  color,  loses  the 
glossiness  of  youth,  perhaps  falls  out ;  the 
teeth  decay  and  loosen  in  their  sockets,  the 
skin  becomes  wrinkled  and  flabby,  the  spleen, 
the  lymphatics,  Peyer's  patches,  and  probably 
other  structures,  tell  but  too  plainly  that  the 
progressive  period  of  life  is  over,  that  degen- 
eration now  controls. 

(2.)  ANATOMICAL  CHANGES  IN  THE  GENITAL 
ORGANS  WHICH  LEAD  TO  THE  MENOPAUSE. 

The  various  organs  and  their  morbid  con- 
ditions will  be  considered  in  the  same  man- 
ner as  in  the  preceding  section. 

The  Ovaries  and  Fallopian  Tubes. — The 
changes  to  which  the  ovaries  are  subject 


ANATOMICAL  CHANGES.  67 

which  have  an  setiological  bearing  upon  the 
menopause  are  very  numerous  indeed.  No 
one  who  has  paid  even  the  most  superficial 
attention  to  the  pathology  of  the  pelvic  or- 
gans in  women  can  have  failed  to  note  the 
astonishing  frequency  and  variety  of  diseases 
which  destroy  the  tissues  of  the  ovaries,  in- 
terfere with  their  function,  and  maintain  a 
necessary  and  intimate  connection  with  the 
menopause.  This  does  not  mean  that  men- 
struation stops  or  even  is  irregular  in  all  cases 
in  which  ovarian  disease  is  present,  for  all 
gynaecologists,  indeed  almost  all  physicians 
who  are  carefully  observant,  are  familiar  with 
cases  in  which  that  function  is  performed 
with  the  utmost  regularity  in  the  presence  of 
most  extensive  disease  of  such  a  character. 

Hence  Hegar  is  not  entirely  correct  in 
asserting  that  menstruation  depends  on  the 
functional  activity  of  the  ovaries,  and  that 
amenorrhcea  is  the  usual  result  of  patho- 
logical conditions  causing  complete  degenera- 
tion of  both  ovaries.  He  is  partly  correct  in 
his  statement  that  exceptions  are  due  to  per- 


68  THE  MENOPAUSE. 

sisting  healthy  parenchyma  which  may  be  in- 
cluded in  the  pedicle  of  an  ovarian  tumor, 
the  tumor  having  been  removed,  and  to  col- 
lateral fluxion  and  stasis.  There  is  an  addi- 
tional element  of  nerve  influence  in  such  cases, 
to  which  attention  has  been  called  by  Arthur 
Johnstone,  and  to  which  reference  may  be 
made  in  the  subsequent  course  of  this  discus- 
sion.* 

The  chief  forms  of  disease  to  which  allu- 
sion has  been  made  in  the  foregoing  portions 
of  this  section  consist  of  neoplasms,  to  which 
the  ovary  is  extremely  susceptible.  Such 
growths  include  fibroma,  sarcoma,  carcinoma, 
tubercle,  and  the  large  family  of  cystomata, 

*  Hoist  reports  a  case,  quoted  by  Borner  (op.  dt.),  in 
which  pregnancy  occurred,  the  patient  dying  before  term, 
and  in  which  both  ovaries  had  undergone  complete  degener- 
ation, one  of  them  being  the  seat  of  malignant  disease. 

Korn  reports  a  case  in  which  a  woman  fifty-three  years  of 
age  had  always  menstruated  regularly,  and  when  seen  by 
him  both  ovaries  were  the  seat  of  malignant  disease. 

In  J.  Williams's  case  pregnancy  occurred  subsequent  to 
the  removal  of  the  left  ovary.  The  case  proceeded  to  term, 
and  during  labor  it  became  necessary  to  remove  the  remain- 
ing ovary  which  had  become  the  seat  of  cystic  disease. 

The  author  has  operated  in  a  number  of  instances  in 
which  menstruation  had  been  uninterrupted  and  in  which 


ANATOMICAL  CHANGES.  69 

though,  as  already  stated,  numerous  cases  of 
undisturbed  menstruation  are  recorded  in 
which  the  ovaries  have  been  found  entirely 
degenerated  and  disorganized  by  such  dis- 
ease. 

Anatomical  changes  in  the  tubes  interfer- 
ing with  menstruation  are  frequently  associ- 
ated with  the  changes  which  have  been  men- 
tioned as  affecting  the  ovaries.  Changes  of 
an  inflammatory  character  are  more  frequent 
in  these  structures  than  are  the  neoplastic. 
Degenerative  or  inflammatory  processes,  if 
limited  to  the  tubes,  would  rarely  repress 
menstruation  or  induce  the  menopause. 

the  ovarian  stroma  had  entirely  disappeared.  Indeed  such 
cases  could  be  multiplied. 

Slavjansky's  well-known  investigations  concerning  paren- 
chymatous  and  interstitial  oophoritis  are  interesting  and  in- 
structive in  this  connection. 

At  the  last  meeting  (1896)  of  the  American  Gynaecological 
Society  cases  were  reported  by  Sutton,  Gordon,  and  others  in 
which  not  only  menstruation  but  pregnancy  and  labor  at 
term  seemed  to  follow  the  removal  of  both  ovaries.  This 
must  mean  either  imperfect  operations,  supernumerary  ova- 
ries, or  transmission  of  ova  to  the  uterus  in  a  way  which  is 
not  clearly  explicable,  and  in  addition  independence  of  men- 
struation in  so  far  as  the  integrity  of  the  ovaries  is  con- 
cerned. 


70  THE  MENOPAUSE. 

Their  integrity  is  not  essential  to  the  con- 
tinuance of  menstruation. 

The  Peritoneum. — In  the  inflammatory 
and  neoplastic  derangements  of  the  peri- 
toneum, the  influence,  with  reference  to  the 
menopause,  is  probably  always  or  nearly  al- 
ways indirect — that  is,  the  pressure  which  a 
tumor  or  a  mass  of  contracting  exudate,  or  a 
collection  of  peritoneal  fluid  of  whatever 
nature,  exerts  upon  the  ovaries,  tubes,  or 
uterus  may  interfere  with  the  circulation  of 
these  organs,  and  impair  their  nutrition  to 
such  a  degree  as  to  induce  the  menopause, 
and  the  same  is  true  with  regard  to  tumors 

O 

developing  from   any  of  the  abdominal  vis- 
cera.* 

The  Uterus.  —  Numerous  are  the  ana- 
tomical changes  in  the  uterus  which  result 
in  the  menopause.  They  may  be  of  an  in- 
flammatory character,  involving  the  periine- 
trium  or  parametrium,  though  such  disturb- 


*  This  interjection,  though  somewhat  wide  of  the  subject 
which  is  immediately  under  consideration,  has  a  bearing 
which,  it  is  believed,  will  be  readily  appreciated. 


ANATOMICAL  CHANGES.  Yl 

ances  often  end  in  resolution.  Should  they 
terminate  in  abscess,  not  only  is  the  effect 
upon  the  vital  forces  in  general  severe  and 
exhausting  on  account  of  the  sepsis  and  vari- 
ous complications  with  the  abdominal  viscera 
which  are  excited,  but  they  are  also  quite 
likely  to  terminate  in  cessation  of  the  men- 
strual function. 

Anatomical  changes  in  the  uterine  mu- 
cous membrane  of  an  inflammatory  character 
may  be  due  to  infection  or  traumatism,  the 
latter  resulting  from  parturition,  the  use  of 
caustics,  or  other  injuries  unconnected  with 
pregnancy  or  parturition,  the  former  arising 
from  the  poison  of  various  infectious  diseases 
which  may  attack  the  uterus,  and  including 
syphilis,  gonorrhoea,  measles,  diphtheria,  ty- 
phoid fever,  or  cholera.  The  inflammation  in 
such  cases  is  followed  by  contraction  and 
atresia,  the  function  of  the  uterine  mucous 
membrane  being  abolished,  the  ovaries  par- 
ticipating in  the  process,  and  the  menopause 
resulting.  Amyloid  disease  affecting  the 
uterus  may  also  interfere  with  menstruation 


72  THE  MENOPAUSE. 

and  induce  the  menopause.  This  form  of 
disease  is,  however,  a  very  rare  one,  only  one 
reported  case  having  been  found  in  literature. 
This  was  reported  long  ago  by  Virchow.* 

Fatty  degeneration  or  infiltration  of  the 
uterus  apart  from  a  general  development  of 
fatty  tissue  may  also  occur,  and  have  a  detri- 
mental action  upon  the  menstrual  function. 
This  subject  has  recently  been  studied  by 
Sanger  f  with  reference  to  the  puerperal 
uterus,  and  in  previous  years  by  Andral, 
Bureau,  Heschl,  Simpson,  Kolliker,  Rold- 
tansky,  and  others. 

Klob  J  regards  fatty  degeneration  of  the 
uterus  as  of  two  varieties,  (1)  post-puerperal 
and  (2)  that  form  which  is  due  to  a  morbid 
condition  of  the  arteries  of  the  uterus  with 
ischsemia,  the  arteries  being  first  rigid,  their 
nutrition  being  impaired,  and  fatty  degenera- 
tion following;. 

O 

Fatty  degeneration  of  the  uterus  may  also 
proceed  from  tuberculosis  or  from  embolism. 

*  Klob,  op.  cit.  %  Op.  cit.,  p.  255. 

f  Annals  of  Gynaecology,  July,  1888. 


ANATOMICAL  CHANGES.  73 

It  begins  from  within  and  works  out\vard, 
and  as  it  progresses  the  ovaries  and  oviducts 
shrivel.  The  menopause  necessarily -follows. 
As  to  the  influence  of  the  neoplasms  of  the 
uterus  upon  the  menopause,  the  myomata,  if 
subperitoneal,  frequently  seem  to  be  unim- 
portant in  this  particular,  excepting  in  those 
cases  in  which,  owing  to  their  size  or  their 
peculiar  situation,  atrophy  is  caused  by  their 
pressure.  The  nutrient  elements  in  such 
cases  go  to  the  tumor  rather  than  to  the 
uterus,  which  accordingly  may  suffer  reduc- 
tion in  its  dimensions.  Frequently  in  such 
cases  the  menopause  is  long  delayed.  With 
the  intramural  growths  menstruation  is  usu- 
ally profuse,  especially  in  those  cases  in  which 
the  tumors  are  implanted  in  the  area  of  great- 
est vascularity  of  the  organ — that  is,  near  the 
entrance  into  the  uterus  of  the  uterine  ar- 
teries. With  the  mucous  and  submucous 
growths  the  conditions  are  also  favorable  to 
great  outpourings  of  blood.  It  is  in  uterine 
disease  of  the  varieties  just  mentioned  that 
women  look  with  greatest  longing  and  hope 


74  THE  MENOPAUSE. 

for  relief  with  the  menopause,  a  hope  and 
longing  which  are  often  delusive  and  just 
ahead  of  one's  grasp.  Who  has  not  seen 
women  with  such  disease  broken  down  and 
anaemic,  prematurely  old,  dying  with  the 
menopause  still  deferred  ?  Should  the  meno- 
pause come  prematurely,  as  it  sometimes  does 
in  such  cases,  it  is  usually  for  the  reason 
that  the  vital  forces  are  exhausted,  the  flow 
ceasing,  as  it  does  with  other  wasting  pro- 
cesses, simply  because  the  vis  nature  has 
given  out. 

With  adenomata  of  the  uterus,  the  in- 
creased nutrition  which  their  presence  im- 
plies necessitates  an  experience  similar  to 
that  which  obtains  with  intramural  myomata. 
In  cases  in  which  they  do  not  assume  a 
malignant  character  (though  some  writers  in- 
sist that  they  are  invariably  malignant)  there 
is  no  reason  for  supposing  that  they  have  any 
tendency  to  favorably  influence  the  meno- 
pause. 

In  the  very  large  majority  of  cases  of 
uterine  disease  it  is  the  involvement  of  the 


ANATOMICAL  CHANGES.  75 

ovaries  which  checks  the  menstrual  flow,  if  it 
is  checked.  Even  cases  in  which  the  uterus 
has  been  removed,  the  ovaries  being  retained, 
have  in  some  instances  continued  their  men- 
strual history  without  interruption,  the  blood 
escaping  through  the  ruptured  capillaries  of 
the  vaginal  scar,  or  by  the  mucous  membrane 
of  the  rectum,  nose,  or  mouth,  or  appearing 
as  stigmata  upon  the  surface  of  the  body. 
Atresia  and  stenosis  of  the  uterine  canal  will, 
of  course,  prevent  the  escape  of  fluid  by  that 
channel,  but  if  the  ovaries  continue  to  func- 
tionate and  the  nexus  in  the  pelvis,  whatever 
it  may  be,  continues  undivided  and  unde- 
stroyed,  menstruation  or  its  substitute  will 
continue  in  one  form  or  another. 

The  Vagina. — The  influence  which  in- 
flammations and  new  growths  of  the  vagina 
and  external  genitals  have  upon  the  meno- 
pause is  necessarily  indirect,  the  effect  being 
produced  through  the  uterus  and  ovaries,  if  it 
exists  at  all.  The  menopause  sometimes  oc- 
curs after  the  infliction  of  severe  injuries 
upon  the  vagina  during  parturition,  atresia 


76  THE  MENOPAUSE. 

and  cicatrization  seriously  crippling  all  the 
pelvic  organs.  Atresia  of  the  vagina  from 
other  causes,  or  obliteration  of  the  vagina  by 
a  neoplasm,  may  lead  to  retention  of  the  men- 
strual secretion  with  great  attendant  disturb- 
ance ;  but  if  the  ovaries  remain  intact,  the 
menopause  is  unlikely  to  occur.  In  several 
cases  of  this  character  which  have  been  under 
the  author's  care  the  unvarying  rule  has  been 
that  the  menopause  did  not  result. 

The  Mammary  Glands. — The  important 
influence  which  is  exerted  by  the  mammary 
glands  upon  the  menstrual  function,  and  con- 
sequently upon  the  menopause,  must  not  be 
overlooked. 

This  subject  has  not  received  the  atten- 
tion at  the  hands  of  gynecologists  which  it 
deserves.  The  mammary  glands  are  a  means 
for  the  diversion  of  a  considerable  portion  of 
the  vital  energy  of  the  uterus ;  their  irrita- 
tion causes  uterine  contraction.  During  the 
period  of  their  highest  functional  activity  the 
pelvic  circulation  is  at  its  minimum,  men- 
struation being  diminished  or  discontinued. 


ANATOMICAL  CHANGES.  77 

The  effect  of  continuous  or  nearly  con- 
tinuous lactation  for  a  prolonged  period,  chil- 
dren being  suckled  almost  without  inter- 
ruption for  several  years,  can  not  fail  in 
women  who  lack  a  superabundance  of  vi- 
tality to  produce  such  a  degree  of  contraction 
of  the  uterus  that  atrophy  and  the  meno- 
pause will  result. 

The  somewhat  rare  condition  of  superin- 
volution  of  the  uterus  may  have  such  a  cause. 
The  author  has  seen  it  result  in  the  meno- 
pause in  the  person  of  a  vigorous  young 
woman  of  twenty-six  who  had  borne  six  chil- 
dren in  rapid  succession. 

In  the  neoplasms  of  the  mammary  glands, 
however,  the  author  has  not  observed  that 
the  influence  upon  the  menstrual  function 
was  marked.  Though  this  is  one  of  the  com- 
monest seats  of  disease  in  women  at  all  ages, 
such  disease  does  not  appear  to  have  any  par- 
ticular bearing  upon  menstruation  or  the 
menopause.  It  is  only  when  the  glands  in 
their  genetic  influence  or  relation,  as  some 
writers  call  it,  are  affected  or  concerned  that 


78  THE  MENOPAUSE. 

we  see  the  diminution  or  cessation  of  men- 
struation. 

That  malignant  disease  of  the  breast  oc- 
curs most  frequently  in  the  decade  between 
forty  and  fifty,  or  the  decade  in  which  the 
menopause  is  of  most  frequent  occurrence,  is 
well  known  and  has  been  the  occasion  of 
investigation  by  Birkett,  Lebert,  Scanzoni, 
Velpeau,  Gross,  and  Winiwarter,  but  that  it 
produces  the  menopause,  except  perhaps 
indirectly,  as  the  nutrition  becomes  greatly 
impaired,  the  facts  do  not  seem  to  indicate. 

3.  ANATOMICAL  CHANGES  WHICH  ARE  COINCI- 
DENTAL WITH  THE  MENOPAUSE,  BUT  WHICH 
AKE  NOT  USUALLY  ITS  CAUSE  NOR  CAUSED 

BY    IT. 

Accidental  or  Incidental  Occurrences  as- 
sociated with  the  Menopause. — The  third  sub- 
ject for  consideration  in  this  connection  con- 
cerns anatomical  changes  in  the  genital  organs 
which  are  incidental  to  or  collateral  with  the 
menopause,  but  which  have  no  setiological  re- 
lation to  it.  The  field  which  is  covered  by 


ANATOMICAL  CHANGES.  79 

this  subject  is  a  large  and  important  one,  for 
it  will  be  apparent  that  there  are  many  dis- 
eased conditions  occurring  during  the  prog- 
ress of  the  menopause,  sometimes  of  a  severe 
or  even  fatal  character,  but  not  essential  to 
it.  The  mistake  has  too  often  been  made  in 
the  past  of  confusing  these  accidental  occur- 
rences with  that  which  was  customary  and 
usual  in  the  history  of  the  menopause. 

Subinvolution. — One  of  the  very  common 
morbid  conditions  which  is  incidental  to  the 
menopause  is  subinvolution  of  the  uterus,  a 
term  which  seems  to  the  author  more  expres- 
sive and  apt  than  areolar  hyperplasia,  or 
chronic  parenchymatous  metritis.  It  im- 
plies, of  course,  that  one  or  more  pregnancies 
have  been  experienced  in  a  given  case.  With 
women  who  have  borne  many  children,  es- 
pecially if  child  bearing  has  been  begun  rather 
late  in  life,  such  a  condition  may  be  easily 
explained. 

Haemorrhages  explained  by  Exuberant 
Nutrition. — The  superabundance  of  tissue  in 
the  uterus  and  the  exuberant  nutrition  of  the 


80  THE  MENOPAUSE. 

endometrial  mucous  membrane  explain  the 
profuse  haemorrhages  which  often  accompany 
this  condition,  prolong  the  menopause,  and 
contribute  greatly  to  the  discomfort  and  in- 
convenience of  the  patient.  In  other  cases 
the  exhaustion  produced  by  the  haemorrhages, 
or  in  part  by  them,  causes  premature  appear- 
ance of  the  menopause,  while  in  yet  others, 
and  perhaps  the  greater  number  of  cases,  the 
effect  upon  the  menopause  is  insignificant. 

Relation  of  Malignant  Diseases  of  the 
Pelvis  to  the  Menopause. — The  entire  series 
of  malignant  diseases  of  the  pelvic  organs, 
whether  internal  or  external,  has  long  been 
regarded  as  bearing  a  peculiar  relation  to  the 
menopause.  It  is  true  that  many  cases  of 
such  disease  take  place  between  the  fortieth 
and  fiftieth  years,  when  the  menopause  most 
frequently  occurs.  We  have  already  alluded 
to  this  coincidence  in  previous  pages  and  to 
other  facts  which  had  a  bearing  in  the  mat- 

O 

ter.  We  shall  also  find  it  necessary  to  allude 
to  it  aimin. 

O 

Galen   and   others   of   the   early   writers 


ANATOMICAL  CHANGES.  81 

originated  the  idea  that  there  was  a  neces- 
sary connection  between  malignant  disease  of 
the  breast  and  uterus  and  the  menopause. 
From  observations  which  were  made  by  Boi- 
vin,  Chiari,  and  others,  the  following  table 
was  constructed,  representing  the  ages  at 
which  uterine  cancer  had  developed. 

Cases. 

Under  20  years 12 

From  20  to  30  years 193 

"   30  "  40   "  519 

"   40  "  50  "  959 

"   50  "  60   "  481 

"   60  "  70  "  279 

Beyond  70  years 210 

The  opinion  of  many  writers  also  is  that 
cancer  of  the  breast  occurs  most  frequently 
in  the  decade  from  forty  to  fifty.  This  has 
already  been  alluded  to.  (See  also  table  on 
page  33.) 

Menopause  is  Conservative;  Malignant 
Disease  is  Destructive. — The  theory  of  the 
menopause,  however,  is  hostile  to  the  plan 
and  progress  of  malignant  disease.  The 
former  is  conservative,  and  consists  essentially 
in  utilizing  to  the  utmost  impaired  and  worn- 
out  tissues  and  processes.  With  malignant 


82  THE  MENOPAUSE. 

disease,  on  the  contrary,  a  tissue  is  built  up  or 
infiltrated  only  to  break  down  and  be  de- 
stroyed, the  destructive  process  continuing 
and  spreading  until  it  annihilates. 

Total  Number  of  Cases  of  Malignant 
Disease  greatest  before  and  after  tlie  Decade 
which  includes  the  Menopause. — It  must  also 
be  remembered  that  the  larger  percentage  of 
cases  of  malignant  disease  of  the  genital  or- 
gans occur  before  and  after  the  menopause. 
When  such  disease  follows  the  menopause 
the  mistake  has  not  infrequently  been  made 
of  attributing  the  coincident  haemorrhage  to 
an  incomplete  menopause  or  to  recurrent 
menstruation.  Such  mistakes  are  less  ex- 
cusable than  they  once  were. 

Warning  should  be  sounded  before  Ma- 
lignant Disease  becomes  too  Extensive.  —  In 
any  event  it  would  be  unreasonable  for  an 
intelligent  physician,  whether  with  or  with- 
out special  knowledge  concerning  the  pelvic 
organs,  to  allow  malignant  disease  of  those 
organs,  accompanied  with  repeated  haemor- 
rhages, to  reach  the  irremediable  stage — that 


ANATOMICAL  CHANGES.  83 

is,  the  stage  when  radical  surgical  measures 
would  be  unavailing  or  impossible — before  he 
called  to  his  assistance  the  expert  gynaecol- 
ogist. 

Fibroid  Tumors  of  the  Uterus  may  sim- 
ulate Malignant  Disease. — The  anatomical 
changes  which  accompany  fibroid  tumors  .of 
the  uterus  during  the  menopause,  especially 
the  degeneration  of  the  uterine  mucous  mem- 
brane with  the  sometimes  attendant  profuse 
haemorrhage,  simulate  malignant  disease,  and 
require  most  careful  attention  in  order  that 
the  differential  diagnosis  may  be  correctly  de- 
termined. Benign  growths  of  different  varie- 
ties may  develop  in  the  genital  organs  coinci- 
dently  with  the  menopause.  Especially  is 
this  true  of  cystic  tumors  of  the  ovary,  the 
active  developmental  period  of  which  may 
continue  even  to  the  most  advanced  age. 

Changes  in  Neoplasms  during  and  after 
Menopause. — Atrophic  changes  in  the  solid 
and  fibrocystic  tumors  of  the  genital  organs 
are  not  as  marked  nor  as  frequent  during  the 
menopause  as  was  formerly  taught.  We  now 


84  THE  MENOPAUSE. 

know  that  tlieir  development  may  continue 
uninterruptedly  in  spite  of  the  menopause, 
that  they  may  enlarge  after  the  menopause 
has  terminated,  and  that  they  may  even  un- 
dergo malignant  degeneration  after  that  pe- 
riod has  passed.* 

Anatomical  Changes  due  to  Inflamma- 
tion.— The  anatomical  changes  which  may  be 
produced  by  purely  inflammatory  processes 
of  the  genital  organs  during  the  menopause 
are  the  same  as  might  occur  if  the  menopause 
wrere  not  present.  They  are  either  of  trau- 
matic or  infectious  origin,  and  are  not  of  fre- 
quent occurrence.  The  tissues  at  this  period 
of  life  are  far  less  susceptible  to  inflammatory 
influences  than  during  the  earlier  part  of  life. 
The  increased  vascularity  which  such  pro- 
cesses imply,  certainly  during  their  early 
stages,  may  possibly  be  accompanied  with  in- 
creased haemorrhage  at  the  returning  men- 
strual epochs,  and  it  would  even  be  possible 
that  the  menopause  might  be  retarded  by 

*  See  in  this  connection  the  writings  of  Muller,  Gusserow, 
and  others  upon  this  subject. 


ANATOMICAL  CHANGES.  85 

such  a  process.  The  infrequency  of  such  pro- 
cesses at  such  a  time  has  resulted  in  the  ab- 
sence of  investigations  for  the  ascertainment 
of  their  particular  significance. 

Destruction  of  the  Generative  Organs  may 
hasten  the  Menopause. — Complete  destruction 
of  the  generative  organs  while  the  menopause 
is  in  progress,  from  whatever  cause,  will  have 
decided  influence  in  accelerating  the  termina- 
tion of  the  menopause,  especially  if  the  uterus 
and  the  adnexa  as  well  are  destroyed  or  re- 
•moved.  If  the  mammary  glands  alone  are 
removed  or  destroyed  there  is  no  evidence,  so 
far  as  the  author  is  aware,  that  the  meno- 
pause will  be  influenced.* 

*  Gross  and  Winiwarter,  in  their  analysis  of  six  hundred 
and  forty-two  cases  of  mammary  cancer,  found  four  hundred 
and  ninety-six  in  which  it  occurred  subsequent  to  the  age  of 
forty.  There  is  nothing  in  their  writings,  nor  in  those  of 
Birkett,  Lebert,  Scanzoni,  Velpeau,  and  Virchow  upon  this 
subject,  to  indicate  that  disease  or  destruction  of  these  glands 
influences  the  menopause. 


86  THE  MENOPAUSE. 


RESUME  OF  THE  FOREGOING  OBSERVATIONS 
CONCERNING  ANATOMICAL  CHANGES,  WITH 
CONCLUSIONS. 

The  Changes  of  the  Menopause  are 
Atrophic  /  The  Time  Required  Varies. — 
The  menopause  is  attended  invariably  by 
anatomical  changes  in  the  genital  organs 
which  are  normally  atrophic  in  character, 
but  the  period  of  time  which  elapses  be- 
fore such  changes  take  place  is  a  variable  one. 

Atrophic  Changes  are  the  more  Uniform 
in  the  Natural  Menopause. — When  it  occurs 
as  a  natural  process  the  atrophic  changes  in 
the  different  organs  are  more  uniform  and 
more  steadily  progressive  than  when  it  is  pre- 
mature or  complicated  by  diseased  conditions 
of  these  organs. 

Diseased  Organs  may  cause  Irregulari- 
ties.— In  cases  in  which  there  is  disease  of  the 
genital  organs  or  of  any  of  the  tissues  which 
compose  them  the  course  of  the  menopause  is 
irregular,  and  there  is  also  irregularity  as  to 
the  anatomical  changes. 

O 


ANATOMICAL  CHANGES.  87 

In  some  cases  the  menopause  is  retarded, 
the  vascular  supply  to  the  genital  organs  be- 
ing abundant,  or  if  the  disease  is  limited  to 
one  of  the  organs  while  the  vascular  supply 
is  withdrawn  from  the  others,  atrophic 
changes  may  take  place  in  the  latter  and 
not  in  the  former. 

In  other  cases,  in  consequence  of  disease, 
traumatism,  or  excessive  function,  the  meno- 
pause may  come  prematurely,  atrophy  of  the 
genital  organs  being  also  premature. 

In  yet  other  cases  in  which  pathological 
anatomical  changes  in  the  genital  organs  have 
taken  place,  the  menopause  is  indefinitely  de- 
ferred, the  organs  do  not  atrophy,  the  dis- 
charge of  blood  continues,  the  tissue  changes 
become  destructive,  and  unless  relieved  by 
art  the  termination  will  eventually  be  a  fatal 
one. 

ADDENDA. 

FARRE.     Anatomy  and  Pathology  of  the  Uterus. 

HENSEN.  Physiologic  der  Zeugung.  Hermann's 
Handbuch  der  Physiologie,  Leipzig,  1881. 

PFLUGER.  Die  teleologische  Mechanik  der  leben- 
digen  Natur.  Archiv  f iir  Physiologie,  xv.  ^ 


88  THE  MENOPAUSE. 

KOBELT.  Die  Mannlichen  und  Weiblichen  "Wol- 
lustorgane  des  Menschen,  Freiburg,  1844. 

VEIT.  Physiologic  der  weiblichen  Geschlechtsor- 
gaue.  Miiller's  Handbuch  der  Geburtshiilfe. 

PUECH.  Des  ovaires  et  de  leurs  anomalies.  Paris, 
1873. 

GROSS.  Tumors  of  the  Mammary  Glaiid.  D.  Ap- 
pleton,  &  Co.,  New  York,  1880. 


CHAPTER  III. 

SOME    OF   THE   FACTORS   WHICH    INFLUENCE   THE 
ADVENT  AND  PROGRESS  OF  THE  MENOPAUSE. 

THE  scope  of  this  chapter  has  included 
more  or  less  which  has  been  stated  in  the 
foregoing  pages  (anatomical  changes,  etc.), 
and  it  will  also  comprehend,  to  a  certain 
extent,  the  material  which  will  be  found  in 
the  chapter  immediately  following  this  one, 
which  will  deal  specifically  with  the  phe- 
nomena peculiar  to  the  menopause.  The 
indulgence  of  the  reader  is  besought  if 

O  O 

his   patience   is   tried  with    apparent  repeti- 
tions. 

The  following  scheme  represents  the 
treatment  of  the  subjects  which  are  to  be 
considered  in  this  chapter. 

89 


90  THE  MENOPAUSE. 

FACTORS  CONSIDERED. 

1.  Age.    2.  Disease  and   traumatisiu.     3.  Climate.    4.  He- 
redity.   5.  Temperament.     6.  Accidental  influences. 

1.  Age. 

The  testimony  of  various  observers  in  different  nations  and 
countries. 


2.  Disease  and  Traumatism. 
f  [I.  General. 

A.  Acute 


a.  Acute.  J  (x-  Puerperal. 


!  c.  Infec- 
and    chronic  J  (_  II.  Local.   -{ 

inflammato- 1  \V-  Nonpuer- j 

npral        I  «•   Tr»U- 
ry  processes. 

L      matic. 

.  b.  Chronic  wasting  diseases  of  various  organs. 

B.  Degenerative  processes. 

C.  Neoplasms. 

D.  Trauma. 

3.  Climate. 

Including  altitude  and  various  atmospheric  conditions. 

4.  Heredity. 

Family,  national,  or  race  peculiarities.     Fertility  and  ster- 
ility. 

5.   Temperament. 

Habits,  occupation,  social  surroundings.    Sexual  excess  and 
abstinence. 

6.  Accidental  Influences. 
Fear,  emotion,  grief,  etc. 

The  Menopause  means  Tissue  Changes. — 
We  have  seen  that  the  menopause  signified 
tissue  changes,  changes  in  structure  in  the 
genital  organs,  and  also  that  at  the  begin- 


ADVENT  AND  PROGRESS.  91 

ning  of  the  process  those  organs  sometimes 
seem  stimulated  to  unusual  activity,  the 
mammary  glands  swelling  and  perhaps  se- 
creting milk,  or  a  fluid  which  resembles  it, 
the  uterus  increasing  in  size  and  vascu- 
larity,  and  the  entire  genital  apparatus  un- 
dergoing a  quite  unusual  degree  of  func- 
tional activity. 

Early  Phenomena  of  tlie  Menopause  may 
indicate  General  Congestion. — The  discharges 
of  blood  from  the  uterus  though  less  fre- 
quent are  more  copious,  the  sexual  appetite 
may  become  intense,  and  this  is  the  more 
noteworthy  since  it  sometimes  occurs  in 
women  who  have  previously  been  insensitive 
and  unresponsive  in  this  respect.  The  change 
in  the  individual,  in  her  disposition,  tem- 
perament, habits,  as  this  process  advances, 
is  sometimes  radical,  marking  quite  as  dis- 
tinct an  era  in  the  life  of  the  person  as  did 
the  advent  of  puberty.  The  waves  advance 
from  puberty  to  the  menopause  ;  from  this 
time  onward  they  recede. 

It  was   observed   in    a  previous    chapter 


92  THE  MENOPAUSE. 

(see  pages  27-38)  in  a  general  way  that  the 
individuals  who  constituted  the  different 
types  of  women  experiencing  the  meno- 
pause varied  in  their  peculiarities,  and  the 
experiences  to  which  they  were  subjected 
were  more  or  less  significant.  Let  us  now 
look  at  the  matter  rather  more  specifically 
and  consider  the  factors  which  influence  the 
advent  and  progress  of  the  menopause. 

Factors  of  Influence  'vary  for  Different 
Women.  —  These  are  not  the  same  for  all 
women  nor  do  they  influence  all  women 
with  the  same  degree  of  effect.  In  the 
course  of  an  experience  of  ten  or  more  years 
of  practice  one  will  find  the  application  of 
each  factor  in  more  or  fewer  cases.  These 
factors  may  be  classified  as  in  the  scheme 
at  the  beginning  of  this  chapter,  as  follows  : 


2.  Disease  and  traumatism,  including  the 

'  O 

influence    of   undeveloped    and    badly    nour- 
ished organs. 

3.  Climate,  including  altitude  and  all  at- 
mospheric conditions. 


ADVENT  AND  PROGRESS.  93 

4.  Heredity,  including  family,  national,  or 
race  peculiarities. 

5.  Temperament,  habits,  occupations,  and 
social  surroundings. 

6.  Accidental  influences,  fear,  misfortune, 
grief,  etc. 

1.  AGE. 

The  age  at  which  the  menopause  occurs 
is  modified,  as  stated  on  page  28,  by  many 
conditions,  and  the  period  of  its  duration  is 
equally  a  variable  quantity. 

In  the  United  States,  at  the  latitude 
of  New  York  and  under  the  influence 
of  a  moist  atmosphere,  the  menopause 
takes  place  in  the  large  majority  of  in- 
stances between  the  fortieth  and  fiftieth 
years. 

The  menopause  was  observed  in  150 
cases  taken  at  random  from  the  histories  of 
many  thousand  women  who  were  seen  at  the 
class  for  gynaecology  at  the  Outdoor  Poor 
Department  of  Belle  vue  Hospital,  in  New 
York  city,  during  a  period  lasting  between 


94  THE  MENOPAUSE. 

four  and  five  years.     The  age  limits  in  these 
cases  were  30  and  53. 

In  96  of  these  cases  menstruation  had 
ended,  in  54  it  still  recurred,  though  in- 
frequently. Of  the  first  of  these  groups 
the  terminations  of  menstruation  were  as  fol- 
lows : 


Age. 
30  

No.  of 
cases. 

2 

Age. 
42  

No. 
case 
2 

31  ... 

0 

43  . 

9 

32 

1 

44  

10 

33 

2 

45  

6 

34  .  .  .  . 

..   .   .2 

46  

5 

35  

0 

47  

5 

36  

1 

48  

10 

37  

6 

49  

4 

38  

5 

50  

2 

39  

8 

51 

1 

40  

4 

52  

.  ...   2 

41.. 

6 

53.. 

3 

The  average  age  of  this  group  was  39f, 
but  it  is  quite  important  to  note  that  63 
were  between  the  ages  of  40  and  50. 

Of  the  second  group,  viz.,  the  54  cases 
in  which  the  interval  of  irregularity  varied 
from  a  few  weeks  to  ten  months,  the  age 
limits  were  38  and  52,  the  average  being 


ADVENT  AND  PROGRESS.  95 

For  the  entire  series  of  150  the  average 
age  was  41^.* 

As  to  the  nationality  of  the  women  in 
this  series,  Irish  and  American  predominated, 
but  all  the  others  had  lived  here  long  enough 
to  be  thoroughly  influenced  by  such  climatic 
and  other  surroundings  as  would  have  a 
bearing  upon  the  appearance  and  progress 
of  the  menopause. 

All  these  women,  be  it  observed,  be- 
longed to  the  class  of  hard  workers. 

The  duration  from  the  beginning  to  the 
end  of  the  menopause  was  not  determinable 
in  the  greater  number  of  these  cases,  unless 
we  should  consider  the  termination  of  men- 
struation as  identical  with  the  termination 
of  the  menopause.  With  the  great  majority 
of  women,  certainly  with  those  who  come  to 
the  notice  of  the  physician,  there  is  no  such 


*  The  much  lower  average  age  in  this  series  than  in  the 
statistics  which  follow  may  be  in  part  due  to  the  smaller 
number  of  cases  involved,  and  in  part  to  the  incident,  not 
easily  explainable,  that  so  large  a  number  as  39  of  the  cases 
which  were  investigated  happened  to  be  40  years  of  age  or 
less. 


96  THE  MENOPAUSE. 

identity,  and  with  many  the  common  phe- 
nomena of  the  menopause,  especially  the  heat 
flashes  or  vasomotor  crises,  are  continued  to 
the  end  of  life,  no  matter  how  prolonged 
life  may  be. 

More  as  a  matter  of  curiosity  or  in- 
formation than  because  any  fundamental 
principles  are  to  be  deduced  from  them, 
the  following  statistical  data,  gathered  from 
various  sources,  have  been  introduced : 

Germany. — Kisch  analyzes  500  cases  from 
among  German  and  Austrian  women,  in 
which  the  menopause  had  been  passed,  the 
termination  of  menstruation  being  probably 
alluded  to.* 

His  figures  are  as  follows: 

Age.  No.  of  cases. 

35-40 48 

40-45 141 

45-50 177 

50-55 89 

France. — Leudet  f  investigated  the  his- 
tories of  170  women  at  Rouen  who  had 

*  See  article  Climakterisches  Alter  in  Real  Encyclopadie. 
t  Comptes  Rendus,  Paris  International  Medical  Congress, 
1867. 


ADVENT  AND  PKOGRESS.  97 

passed  the  menopause,  and  found  the  aver- 
age age  for  those  who  were  in  easy  circum- 
stances 47*4;  for  those  who  lived  amid  the 
surroundings  of  country  life,  47*9;  for  those 
who  were  compelled  to  get  their  living  by 
hard  work,  48'7. 

England  and  France. — Tilt  analyzed  the 
histories  of  1,082  women  in  England  and 
France,  and  found  the  average  age  for  the 
menopause  45 '7. * 

Norway.  —  Faye  found  the  average  age 
in  Norway,  391  cases  being  examined,  to 
be  49.f 

Germany. — In  Berlin,  Mayer  investigated 
1,546  cases  with  the  result  that  the  average 
was  47-034 

Borne^s  Statistics. — Borner  *  found  that 
the  average  for  the  women  of  northern  Eu- 
rope was  higher  than  for  those  in  the  south- 
ern countries,  the  following  data  from  ap- 
proved authorities  being  given  by  him: 

*  Comptes  Rendus,  Paris  International  Medical  Congress, 
1867. 

t  Ibid.  f  Ibid.  *  The  Menopause. 


98  THE  MENOPAUSE. 

Queirel  and  Rouvier  give  46  years 
months  as  the  average  for  Marseilles  women. 
Goth  gave  the  limits  of  39  and  51  years  for 
the  women  of  seven  tribes  in  Transylvania. 

Hussia. — R-odsewitch  gave  the  average  at 
St.  Petersburg  as  48  years  8J  months,  while 
Binsenger,  at  Moscow,  found  it  only  40  to  43. 

Furthermore,  Lieven,  at  St.  Petersburg, 
analyzed  100  cases  in  which  the  age  limits 
were  40  and  53.  In  the  same  series  54 
were  between  47  and  50. 

Denmark. — In  Denmark  312  cases  were 
analyzed  by  Hannover,  the  average  being  44'82. 

The  following  data  were  obtained  by 
the  author  in  the  course  of  an  investigation 
concerning  the  functions  of  the  reproduc- 
tive apparatus  in  our  native  American  In- 
dian women :  * 

Ape  at  cessation 
Names  of  tribes.  of  menstruation. 

Sac  and  Fox 48 

Crow  and  Assiniboine 49-50 

Cmtah 40-50 

Apache 42-53 

Cheyenne  and  Arapahoe 46-73 

Sioux 38-58 

*  See  Transactions,  American  Gynaecological  Society,  1891. 


ADVENT  AND  PROGRESS.  99 

Early  Menopause.  —  As  illustrations  of 
very  early  age  for  the  occurrence  of  the 
menopause  the  Arab  women  of  the  desert 
are  cited,  with  whom  it  is  frequently  said 
to  occur  between  the  ages  of  20  and  30. 

Kisch  tells  of  a  Hungarian  Jewess,  fat 
from  her  youth,  who  menstruated  at  9,  mar- 
ried at  15-J-,  was  sterile,  and  ceased  men- 
struating at  IT.  In  another  of  his  cases 
menstruation  began  at  13,  marriage  occurred 
at  16,  sterility  followed,  and  the  menopause 
came  at  20. 

Mayer  *  saw  two  cases  in  Berlin  in  which 
menstruation  ceased  at  22.  In  one  of  these 
cases  three  children  were  born  after  the  men- 
ses had  ceased.  In  two  others  the  phenom- 
ena of  the  menopause  were  present  at  25. 
One  of  these  women  menstruated  once  in  her 
twenty-fifth  year  after  her  second  labor  ;  she 
subsequently  became  epileptic  and  idiotic 
after  having  experienced  severe  fright.  In 
another  of  Mayer's  cases  the  menopause  came 

*  Comptes  Rendus,  Paris  International  Medical  Congress, 
1867. 


100  THE  MENOPAUSE. 

at  29  in  a  very  fat  woman  who  had  borne  six 
children  at  term  and  had  had  one  miscar- 
riage. 

Brierre  de  Boismont  and  Courty  (quoted 
by  Borner,  op.  cit.)  saw  two  cases  of  meno- 
pause at  21. 

Schlichting  observed  that  the  menopause 
came  at  an  early  age  in  his  experience  with 
Jews  and  Roumanians,  but  no  figures  were 
quoted.* 

Late  Menopause.  —  Illustrations  of  pro- 
longed menstrual  life — that  is,  to  the  age  of 
60 — are  not  very  rare  ;  but  beyond  60  they 
are  very  unusual.  Statements  purporting  to 
narrate  such  prolonged  menstruation  should 
be  examined  very  cautiously  before  being  ac- 
cepted as  facts. 

The  following  cases  are  to  be  found  in  lit- 
erature : 

Battey. — One  by  Battey  in  which  it  is 
said  that  a  woman  of  93  menstruated.f 


*  Zeitschrift  fur  Geburtshulfe  und  Gynakolqgie,  1880,  p. 
203. 

t  Borner,  I.  c. 


ADVENT  AND  PROGEESS.  101 

Pirou. — One  by  Pirou  in  which  a  woman 
menstruated  six  months  during  her  seventy- 
second  year,  then  became  pregnant,  and 
aborted  at  the  second  month.  The  foetus 
was  recovered.* 

Sumpter. — Four  by  Sumpter  in  women  of 
60,  TO,  77,  and  80,  in  which  menstruation  had 
been  continuous  at  regular  intervals,  f 

Norton. — One  by  Norton  in  which  there 
had  been  regular  menstruation  without  cessa- 
tion in  a  woman  of  74.^ 

Two  by  Royle,  one  in  the  sixty-seventh 
and  one  in  the  ninety-third  year.* 

Neumann. — Neumann  has  collected  re- 
ports from  various  authors  who  have  re- 
ported cases  to  him  between  the  sixtieth 
and  one  hundred  and  fourth  years.  | 

Kisch. — The  oldest  case  reported  by 
Kisch  was  60. 

The  author  has  known  families  in  which 
it  seemed  to  be  customary  to  continue  to 

*  Lancet,  1866,  i,  p.  387.  J  Lancet,  ii,  1862,  p.  27. 

t  Lancet,  ii,  1887,  p.  284.  *  Lancet,  ii,  1860,  p.  527. 

\  Monatschrift  fur  Geburtshulfe  und  Gynakologie,  Berlin, 
1895,  i,  p.  238. 


102  THE  MENOPAUSE. 

menstruate  regularly  until  the  fifty-fifth  or 
fifty-sixth  year. 

Conclusion  as  to  Age  Limit.  —  It  would 
therefore  appear  that  the  age  limit  is  not  one 
which  can  be  defined  with  any  approach  to 
accuracy. 

It  is  within  the  truth  to  say  that  the  very 
large  majority  of  women  in  temperate  cli- 
mates reach  the  menopause,  or  at  any  rate 
cease  menstruating,  between  the  fortieth  and 
fiftieth  years.  It  is  probable  that  the  greater 
number  arrive  at  this  condition  between  the 
forty-fifth  and  fiftieth  years,  while  in  the 
tropical  climates  the  decade  between  30  and 
40  is  the  decade  of  the  menopause,  the  ma- 
jority of  the  women  reaching  it  between  35 
and  40. 

2.  DISEASE  AND  TRAUMATISM,  INCLUDING  THE 
INFLUENCE  OF  BADLY  NOURISHED  AND  UN- 
DEVELOPED ORGANS  AS  FACTORS  WHICH 
BEAR  UPON  THE  MENOPAUSE. 

Result  of  Sensitiveness  of  Menstrual  Func- 
tion.— The  menstrual  function  being  one  of 


ADVENT  AND  PROGRESS.  103 

such  extreme  sensitiveness  with  many  women 
it  is  not  strange  that  perturbations  of  the 
general  physical  condition  should  lead  in  some 
instances  to  exaggeration  of  its  phenomena,  in 
others  to  diminished  accentuation  of  the  same, 
and  in  others  to  their  complete  suppression 
or  disappearance. 

Either  of  these  experiences  may  be  inci- 
dental to  the  menopause  when  induced  by 
such  physical  perturbations,  the  menopause, 
as  already  remarked,  applying  not  merely  to 
the  menstrual  flow  or  the  absence  of  it,  but 
to  the  phenomena  associated  with  it.* 

CLASSIFICATION. 

The  conditions  which  are  alluded  to  in  this 
connection  may  be  classified  as  follows : 

1.  Acute  and  chronic  inflammatory  pro- 
cesses. 

2.  Degenerative  processes  (atrophy,  obes- 
ity, defective  development). 

*  The  reader  will  please  bear  in  mind  that  we  are  now 
discussing  the  accidental,  not  the  regular,  conditions  which 
have  a  bearing  upon  the  menopause.  The  regular  or  usual 
concomitants  will  be  considered  in  a  subsequent  chapter. 


104  THE  MENOPAUSE. 

3.  Neoplasms. 

4.  Trauma. 

A.  Acute  Inflammatory  Processes. — The 
acute  inflammatory  processes  which  have  a 
tendency  to  precipitate  the  menopause  are 
not  numerous  nor  are  they  of  very  frequent 
occurrence.  They  are  either  (I)  general  or 
(II)  local. 

Among  the  former  (I)  may  be  mentioned 
measles,  typhoid  and  typhus  fevers,  cholera, 
acute  tuberculosis,  the  acute  infectious  dis- 
eases in  general,  and  the  toxaemia  induced  by 
various  vegetable  and  mineral  poisons — e.  g., 
that  of  acute  malaria  and  that  which  attacks 
workers  in  copper,  lead,  phosphorus,  and  ar- 
senic. The  rationale  of  their  action  consists 
in  the  diversion  of  the  blood  current  from  its 
pelvic  channels  and  the  development  of  a 
general  acute  anaemia  in  connection  with  or 
as  a  sequel  of  the  inflammatory  process.  The 
menopause  is  especially  liable  to  occur  if  the 
individual  attacked  is  already  in  an  enfeebled 
condition  at  the  time  of  the  attack  or  has 
such  weak  recuperative  powers  that  the  ef- 


ADVENT  AND  PROGRESS.  105 

fects  of  the  disease  can  not  readily  be 
thrown  off.  The  defective  nutrition  of  the 
pelvic  organs  in  such  cases  results  in  im- 
pairment of  their  function  and  atrophy 
which  may  prove  permanent,  the  menopause 
being  established  with  or  without  other,  phe- 
nomena. 

(II)  The  local  acute  inflammatory  pro- 
cesses which  lead  to  the  menopause  are  rather 
more  noteworthy  than  those  of  a  general 
or  systemic  character,  because  attention  is 
called  to  the  condition  and  functions  of  the 
pelvic  organs  from  the  beginning.  In  a  gen- 
eral way  they  may  be  divided  into  (x)  those 
which  are  associated  with  the  puerperal  con- 
dition and  (y)  those  which  are  not  so  asso- 
ciated. 

(x)  Of  the  former  the  processes  which 
result  in  the  menopause  are  extremely  de- 
structive, the  ovaries  being  either  disinte- 
grated directly  or  destroyed  by  the  pressure 
of  the  inflammatory  material  effused  about 
them.  Life  itself  is  often  sacrificed  in  such 
cases,  or  the  patient  may  recover  after  a  long 


106  THE  MENOPAUSE. 

convalescence  to  find  that  the  function  of 
menstruation  has  departed. 

The  destruction  of  other  tissues  and  or- 
gans, in  addition  to  the  ovaries,  is  incidental, 
and  is  always  more  or  less  extensive. 

(?/)  The  inflammatory  processes  unasso- 
ciated  with  the  puerperal  condition  and  re- 
sulting in  the  menopause  are  of  (c)  infectious 
or  (d)  traumatic  origin. 

(<?)  Of  the  infectious  processes  gonorrhoea 
is  one  of  the  most  common  and  noteworthy. 
It  is  true  that  it  is  usually  a  chronic  process, 
and  only  develops  its  severer  consequences 
with  the  lapse  of  months  or  years.  There 
are  frequently  cases,  however,  in  which  its 
virulent  effects  upon  the  uterus  and  adnexa 
are  almost  immediate  upon  the  reception  of 
the  poisonous  elements.  The  menstrual  func- 
tion is  immediately  disturbed,  the  flow  being  in 
most  cases  greatly  increased,  and  the  result  in 
a  short  time  is  the  destruction  of  the  ovaries 
and  the  abolition  of  menstruation. 

Such  a  course  of  events  is  frequently  to 
be  observed  when  young  and  active  men  of 


ADVENT  AND  PROGRESS.  107 

vicious  habits,  and  with  manifest  or  latent  gon- 
orrhoea at  the  time  of  marriage,  marry  young 
and  vigorous  girls  with  tissues  which  are  in  the 
highest  possible  condition  of  functional  activ- 
ity. The  author  has  repeatedly  seen  such  cases, 
the  infection  taking  place  almost  immediately 
after  marriage,  and  the  woman  becoming  an  in- 
valid from  that  time  onward  unless  relieved 
by  surgical  procedures.  Infectious  disease  re- 
sulting in  destruction  of  the  ovaries  and  aboli- 
tion of  the  menstrual  function  is  also  of  occa- 
sional occurrence  from  the  carelessness  of 
physicians  who  may  have  introduced  the 
specific  germs  by  means  of  soiled  fingers  or 
instruments.  Fortunately,  with  increasing  in- 
telligence and  cleanliness  on  the  part  of  those 
who  practice  gynaecology,  such  cases  are  be- 
coming rare. 

(d)  Trauinatism  as  the  cause  of  abolition 
of  the  menstrual  function,  by  local  acute  in- 
flammatory process,  may  be  accidental  or 
intentional.  In  accidental  cases,  as,  for  in- 
stance, those  in  which  the  peritoneal  cavity 
is  penetrated,  either  through  the  vagina  or  the 


108  THE  MENOPAUSE. 

abdomen  by  violent  means,  and  the  genital 
organs  seriously  injured,  a  condition  of  acute 
inflammation  resulting,  it  may  be  questioned 
whether  destructive  consequences  would  fol- 
low without  the  abolition  of  the  element  of 
infection.  As  a  matter  of  fact,  it  would  be 
almost  impossible  to  eliminate  the  element  of 
infection  from  such  cases. 

This  class  of  cases  and  also  that  other 
great  class  in  which  the  trauma  is  inflicted 
deliberately  by  the  surgeon,  with  the  inten- 
tion of  producing  the  menopause,  will  come 
under  consideration  again  and  in  a  more 
specific  manner. 

CHRONIC  INFLAMMATORY  PROCESSES    LEADING 
TO  THE  MENOPAUSE. 

Greater  Frequency  of  the  Menopause  from 
Chronic  Inflammatory  Processes. — The  meno- 
pause is  induced  by  chronic  inflammatory 
conditions  and  processes  much  more  fre- 
quently than  by  acute. 

They  are  simply  the  continuation  of  the 
acute  processes,  the  element  of  time  being 


ADVENT  AND  PROGRESS.  109 

added,  and  the  fact  that  the  tissues  in  some 
individuals  have  greater  powers  of  resistance 
than  in  others ;  also  that  an  established  func- 
tion holds  much  more  stubbornly  with  some 
women  than  with  others.  Like  the  acute 
processes,  therefore,  the  chronic  ones  may  be 
puerperal  and  nonpuerperal,  infectious  and 
traumatic ;  they  may  abolish  menstruation  by 
the  anasmia  which  they  induce,  by  the  diver- 
sion of  the  blood  current  away  from  the  pel- 
vis, by  direct  destruction  of  the  ovaries  by 
pressure,  or  by  the  removal  of  the  sources  of 
nutrition  of  the  organs  by  other  means. 

Of  the  systemic  chronic  conditions  which 
are  sufficiently  well  recognized  as  leading  to 
the  menopause,  those  which  are  associated  with 
disease  of  the  lungs,  kidneys,  and  nervous  sys- 
tem are  to  be  mentioned,  while  as  incidental 
processes,  which  will  be  a  matter  for  subse- 
quent consideration,  may  be  mentioned  cer- 
tain lesions  of  the  heart,  liver,  skin,  digestive 
apparatus,  eyes,  etc. 


110  THE  MENOPAUSE. 

WASTING  DISEASES  OF  THE  LUNGS  AND 
KIDNEYS. 

The  chronic  wasting  diseases  of  the  lungs 
and  pleura,  whether  in  the  form  of  tubercu- 
losis, abscess,  congestion,  or  empyeina,  are 
very  frequently  attended  with  abolition  or 
suspension  of  the  menstrual  function.  This 
is  a  conservative  act  on  the  part  of  Nature, 
for  individuals  suffering  with  such  diseases 
have  no  blood  to  spare.  It  is  sometimes 
considered  a  bad  omen  by  the  uninformed, 
especially  when  it  occurs  in  young  women. 
It  is  a  bad  omen  in  the  sense  that  women 
with  such  diseases  frequently  die  as  a  con- 
sequence. If  amelioration  should  occur 
and  the  patient  should  not  have  reached 
middle  life,  if,  moreover,  the  genital  or- 
gans have  not  been  seriously  damaged  by 
disease  in  their  own  structure  or  in  the 
tissues  contiguous  to  them,  the  restoration  of 
the  menstrual  function  would  be  possible. 
The  author  has  never  seen  it  restored, 
when  it  has  once  been  suspended,  in  one 


ADVENT  AND  PROGRESS.  HI 

who  was  suffering  with,  fatal  disease  of  the 
lungs.* 

The  exhausting  effect  of  certain  chronic 
diseases  of  the  kidneys  is  sometimes  mani- 
fested, as  we  have  seen  was  the  case  with 
disease  of  the  lungs,  in  the  disappearance 
of  the  menses.  This  is  true  of  the  chronic 
forms  of  Bright 's  disease  and  of  diabetes. 
The  latter  seems  to  have  an  especial  pre- 
dilection for  disturbing  the  sexual  appetite 
and  apparatus  in  females  as  well  as  in 
males. 

Lecorche  f  has  observed  cessation  of  the 
menses  in  seventy  out  of  a  hundred  and  four- 
teen diabetic  women  who  came  under  his 
care.  This  observation  was  made  not  only  in 
women  who  had  reached  the  forty-fourth  and 
forty-fifth  years,  but  in  those  who  had  reached 

*  The  evidence  from  autopsies  in  matters  like  these  which 
are  under  consideration  is  always  interesting  and  instruc- 
tive. Simpson  observed  a  case  in  which  the  menopause  fol- 
lowed a  first  confinement  in  a  tuberculous  woman.  She  died 
soon  afterward  and  her  ovaries  were  found  to  be  small,  hard, 
and  without  Graafian  follicles.  See  also  Cases  II,  III,  and 
IV  (pp.  44-46)  in  Dalton's  series. 

t  Annales  de  Gynecologic,  October,  1885. 


112  THE  MENOPAUSE. 

only  the  thirtieth  to  the  thirty-fifth.  Tait  * 
has  also  observed  that  this  disease  frequently 
leads  to  the  menopause  at  the  time  when  ar- 
rest of  the  menses  is  about  to  take  place. 
Strojnowski  f  observed  that  atrophy  of  the 
uterus  and  ovaries  attended  diabetes  in  women, 
one  case  in  a  women  thirty  years  of  age  re- 
sulting in  atrophy  of  the  uterus,  and  eleven 
others  resulting  in  atrophy  of  the  ovaries. 
Premature  occurrence  of  the  menopause  was 
also  observed  in  such  cases.  It  would  seem, 
therefore,  that  the  diseases  of  the  kidney 
to  which  reference  has  been  made  might 
be  causative  of  as  well  as  incidental  to  the 
menopause. 

DISEASES   AND  DISOKDERS   OF  THE  NEKVOUS 
SYSTEM. 

Influence  of  Nervous  Diseases  on  the  Meno- 
pause.— The  diseases  and  disorders  of  the  nerv- 
ous system  play  so  prominent  a  part  in  the 

*  Climacteric  Diabetes  in  Women.  Practitioner,  June, 
1886,  p.  401. 

t  Diabetes  with  the  Menopause.  Satellite,  January,  1892, 
vol.  i,  p.  93. 


ADVENT  AND  PEOGEESS.  113 

history  of  the  menopause  that  the  question 
very  naturally  suggests  itself  whether  they 
may  not  sometimes  be  cause  as  well  as  so  fre- 
quently consequence  or  concomitant. 

Abundant  observations  concerning  the 
latter  of  these  two  situations  are  at  hand  and 
will  be  referred  to  in  a  subsequent  chapter, 
while  no  correspondingly  precise  information 
is  available  with  regard  to  the  former. 

It  is  safe  to  say  in  general,  however,  that 
those  diseases  of  the  nervous  system  which 
are  attended  with  marked  anaemia  will  be  fol- 
lowed by  diminution  of  the  menstrual  flow, 
and  in  some  instances  by  its  permanent  arrest. 

General  Paralysis  in  Relation  to  the 
Menopause. — Petit,*  in  an  interesting  paper 
relating  to  this  subject,  remarks  that  Ger- 
mans and  Italians  believe  that  cessation  of 
the  menses  is  a  frequent  cause  of  general 
paralysis,  the  latter  being  thus  constituted 
one  of  the  diseases  of  the  menopause. 


*  The  Relations  of  General  Paralysis  in  Women  to  Certain 
Disorders  of  Menstruation.  Gazette  Medicale,  February  23, 
1889. 

9 


THE  MENOPAUSE. 

Menstrual  Troubles  the  Consequence  of 
Paralysis. — It  is  the  opinion  of  Petit,  how- 
ever, that  the  menstrual  troubles  of  paralytic 
women  may  be  the  direct  or  sympathetic  con- 
sequence instead  of  the  cause  of  cerebral  dis- 
ease. 

In  fifty-nine  cases  of  paralysis  in  women 
which  came  under  his  observation  there  was 
disturbance  of  menstruation  in  fifty-two,  and 
in  every  case  the  menstrual  disturbance  fol- 
lowed the  paralysis.  His  conclusions  are : 

1.  The  development  of  general  paralysis 
in  women   often  leads  to  disorders  of  men- 
struation. 

2.  These  disorders  may  be  characterized 
by  sudden  and  definite  arrest  of  the  menses, 
or   by   irregularity,  though  the  menses  may 
previously  have  been  regular. 

3.  If  there   is   remission   of   the   general 
paralysis,  the  menses  are  usually  restored. 

4.  If  in  a  person   who  is  attacked    with 
diffuse  meningo-encephalitis  there  is  no  exist- 
ing menstrual  disorder,  such  a  person  will  re- 
sist menstrual  disorder  longer  than  one  who 


ADVENT  AND  PROGRESS.  115 

has   had   suppression  or   irregularity   of  the 
menstrual  function. 


B.  INFLUENCE  OF  DEGENERATIVE  PROCESSES, 
ATROPHY,  OBESITY,  DEFECTIVE  DEVELOP- 
MENT, UPON  THE  ADVENT  AND  PROGRESS 
OF  THE  MENOPAUSE. 

Atrophy  producing  the  Menopause  may  be 
Primary  or  Secondary. — Atrophic  processes, 
as  a  cause  of  the  menopause,  may  be  pri- 
mary or  secondary.  The  latter  may  result 
from  inflammatory  conditions  of  an  acute  or 
chronic  character,  the  nutrition  of  the  essen- 
tial genital  organs  being  arrested  or  diverted 
or  it  may  be  directly  shut  off  by  persistent 
and  destructive  pressure  upon  the  organs. 
The  nutrition  is  sometimes  sustained  in  a  re- 
markable manner  through  the  medium  of  the 
adhesions  and  new  tissue  in  which  the  ovaries 
may  be  embedded,  though  the  normal  vessels 
of  supply  may  be  quite  obliterated. 

Atrophy  may  be  due  to  Excess  of  Func- 
tion.— When  the  atrophy  takes  place  without 
the  intervention  of  inflammation  or  neoplasm 


116  THE  MENOPAUSE. 

it  may  be  due  to  individual  or  racial  pecul- 
iarity, to  overstiinulation  or  overactivity,  as 
from  excessive  sexual  indulgence  or  excessive 
childbearing,  or  to  the  anemia  which  results 
from  prolonged  continuance  of  excessive  men- 
struation in  women  of  imperfect  general  con- 
dition. 

Supei'involution  may  induce  the  Meno- 
pause.— That  condition  of  the  uterus  which 
is  known  as  superin volution,  and  which  some- 
times follows  a  series  of  childbirths  which 
rapidly  succeed  each  other,  lactation  also  being 
continuous,  is  usually  an  indication  of  exhaus- 
tion of  the  reproductive  forces  and  a  fore- 
lunner  of  the  menopause.  The  atrophic  con- 
dition of  the  uterus  in  such  cases  is  mani- 
fest enough  and  the  lessening  or  absent  men- 
strual flow  intimates  the  analogous  condition 
of  the  ovaries. 

Obesity  may  induce  the  Menopause. — 
Obesity  has  a  decided  influence  both  as  to 
the  advent  and  the  progress  of  the  meno- 
pause. The  circulation  in  a  very  fat  person 
is  usually  impaired. 


ADVENT  AND  PROGEESS.  117 

The  nutrition  of  the  muscles  and  viscera 
must  suffer  when  the  tendency  to  undue  ac- 
cumulation of  fat  is  present.  In  the  viscera 
such  a  tendency  takes  the  form  of  fatty  de- 
generation, which  is  in  every  way  an  un- 
favorable condition. 

With  obese  individuals  it  is  readily  de- 
termined that  the  pelvic  organs  suffer  in 
common  with  the  others,  their  functions 
likewise  being  involved,  the  menstrual  func- 
tion included^ 

Very  fat  women  menstruate  scantily 
(oligomenorrhcea)  and  suffer  pain  with  each 
returning  period.  They  are  usually  sterile 
or  bear  at  most  one  or  two  children.  This 
fact  was  observed  long  since,  and  was  re- 
corded by  the  ancient  writers  Hippocrates, 
Avicenna,  Laurans,  and  Hoeflerus. 

Formula  concerning  Obesity. — The  law 
which  governs  this  matter  may  be  formulated 
as  follows :  * 

1.  A  woman  under  thirty  years  of  age, 

*  See  also  author's  paper  on  Obesity,  Transactions,  New 
York  State  Medical  Society,  1888,  p.  98. 


118  THE  MENOPAUSE. 

who  bears  four,  five,  six,  or  more  children  in 
rapid  succession  and  suckles  them,  prema- 
turely reaches  the  limit  of  her  reproductive 
capacity,  the  phenomena  of  the  climacteric 
supervening.  This  applies  to  the  average 
woman  under  existing  conditions  of  civiliza- 
tion, and  in  a  marked  degree  to  those  who 
become  obese  after  such  frequent  pregnan- 
cies. 

2.  A  woman  under  thirty  years  of  age  who 
becomes  obese,  from  whatever  cause,  will  usu- 
ally suffer  with  amenorrhoea  or  oligonienor- 
rhoea,  the  menstrual  flow,  if  present  at  all, 
being  accompanied  with  pain,  though  prior 
to  the  accumulation  of  fat  it  may  have  been 
painless.  If  such  women  marry,  they  are 
usually  sterile. 

The  Menopause  from  Defective  Develop- 
ment.— The  menopause  w^hich  results  from 
defective  development  is  easily  comprehended 
and  accounted  for.  Individuals  with  in- 
herited deficiency  of  vital  force,  with  syphi- 
litic or  tuberculous  taint,  whose  lives  are  one 
long  struggle  with  disease,  do  not,  as  a  rule, 


ADVENT  AND  PROGRESS.  119 

possess  great  reproductive  force.  If  the 
menses  are  established  at  all,  they  are  imper- 
fectly performed,  almost  always  with  attend- 
ant pain,  and  terminate  after  a  few  abortive 
attempts. 

The  defective  development  may  be  limited 
to  the  pelvic  organs,  the  remainder  of  the 
body  being  sufficiently  vigorous.  A  defective 
uterus  does  not  necessarily  imply  inability  to 
menstruate,  for  menstruation  and  even  preg- 
nancy continuing  to  term  may  take  place  in 
a  unicornate  uterus  or  one  which  is  otherwise 
defective.  As  a  rule,  however,  menstruation 
will  be  imperfect  and  the  menopause  will 
arrive  early  in  those  women  with  whom  the 
uterus  is  small,  hard,  badly  nourished,  and 
composed  largely  of  connective  tissue,  the 
ovaries  small  and  poorly  nourished,  and  the 
Fallopian  tubes  mere  strings  of  connective 
tissue,  with  a  few  muscular  fibers.  Defective 
development  of  the  genital  organs  in  other 
particulars  may  be  present,  and  the  function 
of  menstruation  be  unimpaired,  at  least  for  a 
time.  The  vagina  may  be  defective  or  even 


120  THE  MENOPAUSE. 

absent,  the  hymen  may  be  preternaturally 
firm,  the  os  uteri  may  be  nearly  or  quite  oc- 
cluded, and  yet  menstruation  go  on  regularly, 
a  part  of  the  menstrual  flux  being  reabsorbed 
and  the  residue  remaining  to  distend  the 
organ  which  contains  it.  The  consequences 
may  be  serious  if  the  retained  material  is  not 
liberated  and  the  passages  made  pervious  for 
the  future ;  but  if  that  is  done,  the  function 
of  menstruation  may  continue  uninterrupted 
by  this  incident. 

C.  NEOPLASMS,    THEIK   INFLUENCE   UPON  THE 
MENOPAUSE. 

The  Influence  of  Neoplasms  on  the  Meno- 
pause is  very  Great. — The  influence  of  neo- 
plasms as  a  factor  which  has  a  bearing  in 
hastening  or  retarding  the  menopause  is  very 
great,  in  fact,  there  is  no  factor  which  bears 
upon  the  subject  which  is  of  greater  impor- 
tance. The  conditions  of  the  question  vary 
according  as  the  neoplasm  is  intrinsic,  devel- 
oped within  the  structure  of  the  pelvic 
organs,  or  extrinsic,  developed  without  and 


ADVENT  AND  PEOGRESS.  121 

bearing  only  an  accidental  relation  to 
them. 

Neoplasms  which  are  External  to  the  Or- 
gans essential  to  Menstruation. — When  the 
neoplasm  is  external  to  the  organs  which  are 
essential  to  menstruation  the  field  for  consid- 
eration becomes  a  rather  restricted  one.  Those 
cases  are  excluded  in  which  the  process  is 
simple  and  entirely  an  inflammatory  one, 
though  the  resulting  exudate  may  cement  the 
extra  pelvic  organs  into  a  mass  which  pre- 
sents the  gross  appearance  of  a  neoplasm  and 
exerts  unfavorable  influence  upon  the  men- 
strual function.  Such  cases  have  already 
been  considered. 

Malignant  Growths  predominate. — The 
neoplasms  which  are  now  to  be  discussed 
may  be  benign  or  malignant,  but  the  latter 
predominate.  They  include  the  morbid 
growths  which  are  sometimes  associated  with 
tuberculosis  of  the  abdominal  viscera,  ascitic 
accumulations  which  are  associated  with  va- 
rious diseases  of  those  viscera,  the  rare  cystic 
neoplasms  of  the  pancreas,  kidneys,  mesen- 


122  THE  MENOPAUSE. 

tery,  etc.,  usually  of  a  benign  character,  and 
the  entire  series  of  malignant  growths  of  the 
liver,  mesentery,  omentum,  kidneys — in  fact, 
all  the  abdominal  viscera.  These  diseased 
conditions  attack  women  at  all  periods  of  life, 
certain  forms  being  encountered  more  fre- 
quently at  one  period  than  another,  and  influ- 
ence the  menstrual  function,  both  through 

'  O 

their  immediate  contact  with  the  genital  or- 
gans and  their  influence  upon  the  general 
nutrition. 

Pressure  may  cause  Atrophy  of  tlw  Or- 
gans of  Generation. — The  pressure  influence 
may  be  sufficient  to  occasion  atrophy  of  the  es- 
sential organs  of  menstruation,  as  has  been 
observed  with  respect  to  other  conditions,  in 
which  case  the  menstrual  function  might  be 
suspended  or  an  intimate  bond  of  union 
might  be  established  between  neoplasm  and 
pelvic  organs,  with  the  result  of  greatly 
increasing  the  vascular  supply  of  those  organs 
and  greatly  increasing  the  menstrual  flow. 

Malignant  Growths  may  increase  the 
Menstrual  Flow. — Increase  of  the  menstrual 


ADVENT  AND  PROGRESS.  123 

flow  is  the  usual  course  of  events  with  the 
malignant  neoplasms.  They  are  of  rapid 
growth,  often  cause  great  distress  by  their 

o  «/ 

pressure  influence,  and  quickly  induce,  by 
means  of  the  exhausting  discharges  which 
accompany  them,  an  ansemia  which  is  only  a 
forerunner  of  the  fatal  issue  soon  to  occur. 
When  the  neoplasm  is  developed  from  the 
pelvic  organs  themselves,  its  influence  upon 
the  menstrual  function  is  often  a  matter  of 
vital  importance.  The  current  opinions  upon 
certain  aspects  of  the  subject  are  undergoing 
change  which  will  be  referred  to  at  a  later 
stao-e  of  the  discussion. 

O 

Here  also  neoplasms  are  to  be  considered, 
\vith  reference  to  their  effect  upon  the  meno- 
pause, as  benign  or  maJignant,  the  distin- 
guishing feature  of  the  latter  being  that  they 
always  provoke  an  increase  in  the  discharge 
from  the  uterus,  while  with  the  former  the 
menopause  is  in  some  cases  hastened,  in  others 
retarded,  while  in  others  no  effect  is  apparent. 

Tfie  -Evil  Effects  of  Malignant  Neoplasms 
are  manifold. — The  evil  effects  of  the  ma- 


124  THE  MENOPAUSE. 

lignant  neoplasms,  whether  of  the  uterus, 
ovaries,  or  tubes,  and  whether  solid  or  cystic, 
are  manifold.  The  constitutional  effects,  anae- 
mia and  debility,  do  not  in  this  case  tend  to 
lessen  the  flow  of  blood  from  the  uterus, 
neither  does  the  pressure  of  even  large  tumors 
produce  the  atrophy  of  the  genital  organs  and 
subsequent  cessation  of  uterine  haemorrhage 
which  sometimes  occurs  with  benign  tumors. 
On  the  contrary,  the  malignant  disease  almost 
always  signifies  greatly  increased  vascularity, 
and  not  only  increased  loss  of  blood  at  the 
menstrual  epoch,  but  at  irregular  periods  as 
well.  Great  loss  of  blood  from  the  uterus 
is  so  common  a  symptom  of  malignant  disease 
of  that  organ  or  its  adnexa  that  the  possibil- 
ity of  such  disease  must  always  be  considered 
when  such  haemorrhage  occurs. 

Hemorrhages  during  the  Menopause  call 
for  Careful  A  Mention. — Especially  should  one 
be  very  watchful  if  the  profuse  haemorrhage 
occurs  during  the  period  of  the  menopause, 
while  if  it  occurs  years  after  the  disappear- 
ance of  the  menses  it  furnishes  one  of  the 


ADVENT  AND  PROGRESS.  125 

strongest  possible  evidences  that  malignant 
disease  is  present. 

Neoplasms,  apart  from  the  Genital  Ap- 
paratus, not  under  discussion. — Neoplasms 
of  the  pelvic  organs,  apart  from  the  organs  of 
the  genital  apparatus,  are  not  especially  under 
discussion.  They  would  include  tumors  of 
the  bladder,  rectum,  peritoneum,  and  bony 
structure  of  the  pelvis,  and  the  same  remarks 
would  apply  to  them  that  were  made  concern- 
ing neoplasms  of  the  abdominal  cavity. 

Pressure  Influence  of  Solid  Tumors  usu- 
ally greater  than  that  of  Cystic. — The  benign 
neoplasms  of  the  pelvic  genital  organs,  in 
their  influence  upon  menstruation  and  the 
menopause,  may  be  considered  as  solid  and 
cystic,  as  acting  by  simple  contact  and  pres- 
sure, and  as  having  additional  action  by  means 
of  the  organic  union  which  results  when  a 
neoplasm  becomes  attached  to  an  organ  by 
adhesive  inflammation.  The  pressure  influ- 
ence of  solid  neoplasms  upon  the  structure 
which  is  essential  to  menstruation — that  is, 
the  influence  which  causes  atrophy  when 


126  THE  MENOPAUSE. 

the  structures  fill  the  pelvis — is  usually 
greater  than  that  of  the  cystic.  We  would 
therefore  expect  that  the  abolition  of  men- 
struation by  destructive  pressure  upon  the 
ovaries  would  take  place  more  quickly  with  a 
solid  than  with  a  cystic  tumor. 

Ovarian  Tumors  may  be  very  Large  and 
Menstruation  remain  undisturbed. — A  tumor 
of  the  ovary  may  reach  a  great  size,  or  both 
ovaries  may  be  involved  in  extensive  cyst 
formation,  menstruation  continuing  uninter- 
ruptedly meanwhile  and  without  especial  dis- 
turbance. But  when  the  tumors  are  removed 
menstruation  either  stops  at  once  or  within  a 
very  short  time,  which  shows  either  that 
menstruation  was  continued  by  virtue  of  a 
portion  of  ovarian  tissue  which  remained  in- 
tact, or  by  the  vital  connection  with  the  re- 
maining pelvic  organs  which  continues  unim- 
paired. Whether  this  means  the  presence  of 
an  essential  nerve  structure  or  a  glandular 
structure  which  has  been  found  by  anatomists 
who  were  unable  to  find  the  nerve  described 
by  Johnstone,  is  at  this  moment  undecided. 


ADVENT  AND  PROGRESS.  127 

The  benign  tumors,  involving  more  or  less 
of  the  structure  of  the  uterus,  are  either  solid 
or  nbro-cystic,  the  latter  being  infrequent 
compared  with  the  former. 

Influence  of  Uterine  Tumors  upon  Men- 
struation.— When  the  relation  of  the  tumor 
to  the  uterus  is  not  very  intimate — that  is, 
when  the  bond  of  union  is  a  stalk  or  pedicle 
— the  influence  of  the  tumor  upon  menstrua- 
tion and  the  menopause  may  be  slight  or 
nil.  When  the  tumor  is  within  the  wall  of 
the  uterus  or  has  protruded  into  its  cavity, 
its  influence  upon  menstruation  is  consider- 
able ;  the  blood  stream  which  nurtures  the 
tumor  must  nurture  the  uterus  as  well,  and 
the  action  and  reaction  of  uterus  and  tumor 
upon  each  other,  in  this  particular,  become 
the  more  marked  as  the  site  of  the  tumor  ap- 
proaches the  area  of  greatest  vascularity  of  the 
uterus — that  is,  the  area  contiguous  to  the 
entry  of  the  uterine  artery  into  and  the  exit 
of  the  uterine  vein  from  the  uterus.  In  such 
cases  menstruation  is  almost  certain  to  be 
profuse,  and  in  many  cases  there  are  effusions 


128  THE  MENOPAUSE. 

of  blood,  aside  from  the  menstrual  flow,  at 
frequent  intervals ;  in  not  a  few  cases  the 
leakage  of  blood  is  almost  continuous. 

The  Opinion  that  the  Menopause  will  see 
the  end  of  Uterine  Haemorrhages  is  frequently 
erroneous. — It  was  formerly  supposed  that 
all  these  cases  would  get  well  if  they  could 
only  pass  the  trying  ordeal  of  the  menopause, 
and  they  were  encouraged  to  hold  out  until 
that  event  should  occur. 

But  the  hopes  which  were  aroused  were 
often  delusive — 

"The  baseless  fabric  of  a  dream." 

The  menopause  constantly  eluded  these  suf- 
ferers like  an  aggravating  Will-o'-the-wisp,  and 
many  of  them  died  from  sheer  exhaustion  and 
loss  of  blood,  without  the  least  amelioration 
in  the  conditions  relating  to  the  uterine  tu- 

O 

rnor.  All  this  was  the  result  of  an  imperfect 
pathology  and  of  imperfect  observation.  It 
is  true  that  some  uterine  tumors  ameliorate 
with  the  menopause.  Some  were  never  the 
source  of  any  particular  trouble,  especially 
those  with  w^hich  the  pedicle  is  a  long  one. 


ADVENT  AND  PROGRESS.  129 

Others  may  have  given  much  discomfort,  and 
if  they  occur  in  women  who  have  never  been 
pregnant  and  who  never  have  sexual  inter- 
course— in  other  words,  if  the  only  congestion 
to  which  they  are  subject  is  the  congestion  of 
menstruation — they  sometimes  improve  with 
the  menopause. 

In  many  Cases  of  fibroid  of  the  Uterus 
the  Menopause  does  not  come  unless  it  is  in- 
duced.— In  many  other  cases,  perhaps  the  ma- 
jority, the  menopause  brings  no  relief,  or 
rather  the  menopause  does  not  take  place, 
and  the  sufferers  continue  to  lose  blood  and 
vitality  indefinitely  unless  radical  measures 
are  adopted  for  their  relief.  Fortunately, 
such  measures  of  relief  are  now  entirely 
available  in  any  portion  of  the  world  where 
the  science  and  art  of  gynaecology  are  suc- 
cessfully cultivated,  and  the  old  argument 
that  the  menopause  will  bring  a  cure  be- 
comes true,  but  under  conditions  which  are 
entirely  different  from  those  which  once  pre- 
vailed. 


10 


130  THE  MENOPAUSE. 

D.  TKAUMA  AS  A  FACTOR  IN  THE  DEVELOP- 
MENT or  THE  MENOPAUSE. 

Destruction  of  the  Genital  Organs  by  Ac- 
cidental Traamatism  very  Rare. — If  we  con- 
sider the  element  trauma  or  traumatism 
merely  as  an  accidental  condition  resulting 
in  the  menopause,  it  would  not  require  very 
extended  notice.  One  of  the  rarest  occur- 
rences in  the  world  is  an  accident  which  de- 
stroys the  genital  organs  and,  as  a  conse- 
quence, abolishes  the  menstrual  function.  It 
is  possible  for  a  woman  to  fall  astride  a 
picket  fence,  or  to  have  the  leg  of  a  chair  or 
a  poker  or  some  other  brutal  instrument 
thrust  into  her  vagina,  or  to  be  ripped  open 
by  the  horn  of  an  angry  animal,  and,  if  she 
survives  the  accident,  to  do  so  with  her 
sexual  organs  destroyed  or  so  mutilated  that 
menstruation  would  not  recur.  An  accident 
of  such  a  character  would  excite  interest 
quite  as  much  on  account  of  its  peculiarity 
as  from  the  seriousness  of  its  nature  and  im- 
port. 


ADVENT  AND  PROGRESS.  131 

The  Artificial  or  Surgically  Induced  Meno- 
pause.— There  is,  however,  a  form  of  trauma- 
tism  which  results  almost  uniformly  in  the 
menopause  which  occurs  with  great  frequency 
at  the  present  time,  and  is  inflicted  delib- 
erately by  the  surgeon  with  the  knowledge 
and  intention  that  the  menopause  shall  re- 
sult. Such  a  result  thus  produced  is  known 
as  the  artificial  menopause,  and  has  intro- 
duced a  new  era  into  surgical  practice,  scat- 
tering blessings  broadcast,  producing  good 
results  in  some  cases  and  bad  results  in 
others. 

It  will  be  considered  at  greater  length  in 
another  chapter. 

3.  CLIMATE,  INCLUDING  ALTITUDE  AND  ALL 
ATMOSPHERIC  CONDITIONS. 

Atmospheric  Influence  varies  with  Differ- 
ent Conditions. — The  influence  of  atmospheric 
conditions  upon  the  menstrual  function  is  of 
course  much  more  marked  in  some  individ- 
uals and  families  than  in  others. 

The   statements   which   are  to   be   made 


132  THE  MENOPAUSE: 

upon  this  subject  must  be  received  with  a 
certain  amount  of  latitude,  though  it  is  be- 
lieved that  the  observations  have  in  most 
cases  been  sufficiently  extensive  and  the  con- 
clusions sufficiently  accurate  to  warrant  their 
acceptance. 

The  question  of  the  establishment  and 
the  continuance  of  menstruation  naturally 
calls  for  a  certain  degree  of  consideration  in 
this  connection. 

An  Out-of-door  Life  may  favor  the  pro- 
longation of  the  Menstrual  J^ra. — Bearing 
upon  this  subject  is  the  observation  which 
has  been  frequently  made  that  country 
women  retain  the  menstrual  function  longer 
than  city  women,  and  workingwomen — that 
is,  those  who  work  out  of  doors  and  in  the 
fields — providing  that  their  labor  is  not  of 
too  severe  a  character,  retain  it  still  longer. 
Thus  Leudet  *  found  the  average  age  at  the 
menopause  of  the  first  of  these  three  classes 
in  question  47*4  years,  of  the  second  47*9,  of 
the  third  48'7. 

*  Comptes  Rendus,  Paris,  1867. 


ADVENT  AND  PROGRESS.  133 

Observations  as  to  the  Age  of  the  Meno- 
pause by  Various  Writers. — The  same  rela- 
tive differences  obtained  in  Leudet's  experi- 
ence in  the  establishment  of  the  menstrual 
function. 

Somewhat  similar  facts  were  observed  by 
Kisch,  whose  book  on  the  menopause  has 
been  frequently  alluded  to.  Kisch  and  Bor- 
ner  observed  also  that  in  the  northern  coun- 
tries of  Europe  the  menopause  came  later 
than  in  the  southern. 

On  the  other  hand,  it  does  not  always 
follow  that  early  puberty,  which  is  sufficiently 
frequent  to  become  almost  the  rule  in  warm 
countries,  means  necessarily  an  early  meno- 
pause. Upon  this  latter  point  Tilt  has  ob- 
served *  that  while  the  average  age  of  puberty 
among  the  Hindus  is  twelve  years,  the  meno- 
pause is  frequently  delayed  until  the  age  of 
fifty.  The  same  author  states  that  the  aver 
age  for  the  menopause  in  Norway  was  49, 
puberty  averaging  16*375,  while  in  England 
and  France  the  average  was  45'7. 

*  Comptes  Rendus,  Paris,  1867,  p.  187. 


134  THE  MENOPAUSE. 

In  the  latitude  and  climate  of  St.  Peters- 
burg 100  cases  were  analyzed  by  Lieven,  the 
limits  of  puberty  being  11  and  22,  while 
those  of  the  menopause  were  40  and  53  ;  but 
in  54  of  these  cases  the  limits  were  47 
and  50. 

In  Denmark  Hannover  found  the  average 
age  for  the  menopause  44*82,  which  seems  a 
low  estimate  for  that  latitude  and  climate. 
Another  writer  placed  the  average  of  pu- 
berty for  nearly  4,000  cases  at  16  years  10 
months  5  days.  For  the  north  and  center 
of  Germany  Mayer*  found  the  average  of 
puberty  for  the  upper  classes  15*19,  for  the 
lower  classes  16*50,  for  country  girls  15*20, 
for  city  girls  15*98.  He  satisfied  himself  that 
the  age  of  puberty  varied  directly  with  the 
altitude.  The  average  for  the  menopause  at 
Berlin  in  1,546  cases  which  he  analyzed  was 


*  Comptes  Rendus,  Paris,  1867. 

f  The  foregoing  data  have  been  already  quoted,  see  pages 
99  and  100,  but  in  the  former  instance  they  were  adduced  to 
show  the  influence  of  age  with  reference  to  the  menopause  ; 
now  they  are  invoked  in  respect  to  climate. 


ADVENT  AND  PROGRESS.  135 

Cortajarena  is  on  record  as  believing  that 
climate,  race,  and  differing  conditions  of  life 
have  no  direct  and  immediate  effect  on  men- 
struation, but  that  their  effect  is  subordinate 
to  nutrition. 

Different  Effects  of  Tropical  and  Tem- 
perate Climates. — It  would  seem  to  be  both 
reasonable  and  logical  that  the  same  forces 
which  in  the  tropics  result  in  rank  vegetation 
and  early  maturity  should  have  a  like  effect 
in  the  physical  development  of  human  beings, 
unless  means  were  taken  to  prevent  or  neu- 
tralize such  results.  The  forces  in  question 
are  mainly  high  temperature,  abundance  of 
food,  and  vis  inertice,  and  they  may  and  in- 
deed do  prove  deleterious  when  considered 
from  certain  points  of  view ;  thus  India  can 
not  be  colonized  by  the  English  as  they  have 
colonized  Australia  and  America,  for  the 
simple  reason  that  the  intense  and  prolonged 
heat  of  the  climate  is  too  exhausting  to  their 
vitality,  and  their  reproductive  force  is  said 
to  be  spent  with  the  second  generation. 

In  the  temperate  climates  growth  and  ma- 


136  THE  MENOPAUSE. 

turity  are  slowly  acquired,  vitality  is  longer 
retained  than  in  the  tropics,  and  we  should 
consequently  be  led  to  expect  a  somewhat 
later  occurrence  of  the  menopause.  In  very 
cold  climates  the  forces  which  dwarf  vegeta- 
tion and  limit  its  fecundity  have  an  analogous 
effect  upon  the  vital  functions  of  man.  For 
example,  the  Eskimos  are  small  in  stature, 
the  women  do  not  menstruate  until  the 
twentieth  year  or  later,  and  the  number  of 
children  in  a  family  seldom  exceeds  three; 
oftener  it  is  less  than  that  number.  Both 
the  menstrual  function  and  vital  force  itself 
are  exhausted  at  an  early  age. 

Varying  Effect  of  Atmospheric  Pressure. 
— The  effect  of  atmospheric  pressure  upon 
menstruation  and  indirectly  upon  the  meno- 
pause deserves  a  word  in  passing.  Of  course, 
when  the  atmospheric  pressure  is  great,  as  at 
the  sea  level  and  by  the  seashore  or  on  the 
sea,  the  internal  pressure  that  is  within  the 
cavities  and  canals  of  the  body  is  exposed  to 
its  greatest  resistance ;  while  as  one  advances 

into  the  interior  and  ascends  to  higher  and 

~ 


ADVENT  AND  PROGRESS.  137 

higher  elevations  the  pressure  relations  are 
reversed,  the  external  diminishing  v/ith  the 
rarefication  of  the  atmosphere  and  the  ten- 
sion within  the  vessels  and  the  cavities  in- 
creasing;. 

O 

Suspension  of  Menstrual  function  with 
Change  of  Residence. — A  woman  who  passes 
from  the  interior  of  a  country  to  the  seashore 
or  who  takes  a  sea  voyage  will  in  most  cases 
observe  that  her  menstrual  function  is  for 
the  time  suspended,  or  the  flow  is  diminished, 
or  she  suffers  pain  to  which  she  may  have 
been  a  stranger  at  previous  menstrual  epochs. 
In  certain  cases  it  is  possible  that  the  meno- 
pause may  result  from  a  sea  voyage  or  the 
transfer  of  one's  residence  to  the  seashore,  ad- 
justment to  surrounding  conditions  in  refer- 
ence to  the  menstrual  function  not  being 
effected.  This  fact  is  too  often  overlooked 
in  the  treatment  of  women  who  are  ap- 
proaching the  menopause,  and  it  should  be 
carefully  considered  in  the  hygienic  regula- 
tions which  are  formulated  for  such  indi- 
viduals. 


138  THE  MENOPAUSE. 

In  prescribing  Change  of  Residence  the 
Effect   of  Atmospheric  Pressure  may   be   a 

Matter  for  Serious   Consideration. — The   ac- 
*.          J  . 
tion  of  physical  laws  upon  the  surface  and 

the  interior  of  the  body  should  also  be  taken 
into  consideration  when  a  woman  removes 
her  residence  to  a  locality  in  which  the  at- 
mospheric pressure  is  low.  Haemorrhage  is 
favored  by  such  physical  conditions,  and  the 
menopause  may  be  indefinitely  prolonged  or 
deferred  by  them.  Especially  is  this  the  case 
with  those  who  are  suffering  with  uterine  dis- 
ease in  which  haemorrhage  is  a  noteworthy 
feature.  The  same  physical  conditions  which 
favor  nosebleed,  haemoptysis,  purpura,  etc., 
in  those  who  are  susceptible  to  such  acci- 
dents will  favor  haemorrhage  from  the  uterus, 
and,  to  a  greater  or  less  degree,  delay  the 
menopause  with  individuals  who  suffer  with 
uterine  disease  in  which  haemorrhage  is  a 
characteristic  symptom.  The  fact  that  ad- 
justment to  climatic  surroundings  is  possible 
is  of  course  admitted,  but  the  risk  in  acquir- 
ing such  adjustment  and  acclimation  is  some- 


ADVENT  AND  PROGRESS.  139 

times  as  great  with  uterine  disease  as  with 
pulmonary  disease. 

The  Risk  in  acquiring  Acclimation  at 
great  Altitudes  is  sometimes  Considerable.— 
The  subject  of  climatology  in  its  relation 
to  the  diseases  peculiar  to  women  is  one 
which  has  been  almost  universally  ignored 
by  those  who  teach  as  well  as  by  those  who 
practice  gynaBcology.  It  offers  a  promising 
field  for  future  investigation  in  a  limited 
range  of  conditions. 

4.  HEBEDITY,  INCLUDING   FAMILY,  NATIONAL, 
OE  RACE  PECULIAEITIES. 

Reproduction  of  Family  Peculiarities.— 
One  of  the  most  plausible  propositions  in 
Darwin's  theory  of  evolution  is  that  the 
habits  and  tendencies  of  parents  are  prone  to 
produce  certain  peculiarities  which  are  re- 
peated, sometimes  with  more  or  less  modifica- 
tion or  accentuation  in  their  offspring,  lead- 
ing in  process  of  time  to  a  change  of  type. 

While  this  may  not  hold  as  a  universal 
law  and  thus  enables  many  a  keen  observer 


140  THE  MENOPAUSE. 

to  deny  that  it  holds  as  a  law  at  all,  any  phy- 
sician who  has  practiced  within  a  limited  area 
of  territory  and  has  observed  the  characteris- 
tics of  the  families  in  his  clientele  for  a  long 
period  of  years  can  recall  plenty  of  instances 
in  which  parental  peculiarities  have  been  re- 
produced from  one  generation  to  another. 

The  menstrual  function  is  no  exception  to 
the  somatic  conditions  which  are  influenced 
by  heredity. 

Lateness  of  the  Menopause  as  a  Family 
Characteristic. — Lateness  in  the  appearance 
of  the  menopause  is  a  characteristic  in  some 
families.  The  author  is  acquainted  with  such 
family  histories  in  which  the  fifty-fifth  or 
fifty-sixth  year  is  looked  upon  as  the  time 
when  the  menopause  may  be  expected,  this 
having  been  the  rule  for  two  or  more  genera- 
tions. In  some  families  the  menopause  comes 
abruptly,  menstruation  suddenly  ceasing  for- 
ever; in  others  irregular  periods  of  menstrua- 
tion drag  along  through  one  or  more  years. 
The  bleedings  are  insignificant  in  some  fami- 
lies ;  in  others  they  are  always  profuse 


ADVENT  AND  PROGRESS.  141 

though  the  result  may  not  be  malignant  dis- 
ease. 

family  Taint.  —  Family  taint  probably 
has  something  to  do  with  the  fact  that  both 
the  men  and  the  women  in  certain  families 
develop  malignant  disease  as  age  advances. 
There  seems  to  be  no  more  inherent  improba- 
bility as  to  such  a  tendency,  which  doubtless 
is  outlived  or  overcome  in  some  cases,  than 
there  is  as  to  the  manifest  tendency  in  other 
families  to  the  development  of  tuberculosis, 
scrofula,  etc.  Certain  family  or  race  traits  in 
respect  to  the  menopause  become  intensified 
as  time  progresses,  while  others  become  modi- 
fied and  gradually  lost.  Especially  is  there  a 
modification  of  these  traits  when  the  family 
or  the  race  migrates  to  a  locality  in  which 
the  climatic  conditions  are  radically  different 
from  those  to  which  they  have  been  accus- 
tomed. 

Peculiarities  of  Jewesses  and  Indians. — 
Jewish  women,  as  a  race,  suffer  less  during 
the  menopause  than  other  races,  whether  on 
account  of  their  ceremonial  laws  and  customs 


142  THE  MENOPAUSE. 

or  for  some  other  reason,  the  writer  is  unable 
to  state. 

The  American  Indian  women  are  very 
rarely  conscious  of  anything  unusual  during 
the  menopause,  and  they  may  be  taken  as  the 
type,  in  regard  to  this  matter,  of  savages  and 
barbarians  in  general  whose  surroundings  are 
of  the  average  degree  of  comfort  and  en- 
lightenment. The  phenomena  connected  with 
the  nervous  system  are  very  prominent  and 
decided  during  the  menopause,  and  the  in- 
fluence of  family  traits  and  tendencies  is  most 
pronounced  in  this  direction.  Melancholia, 
cerebral  congestion,  hysteria,  etc.,  are  the  an- 
ticipated accompaniments  of  the  menopause 
in  certain  households.  Perhaps  if  they  were 
not  expected,  in  a  sort  of  historical  succes- 
sion, they  would  not  appear. 

The  Menopause  is  Insignificant  with  tlie 
Majority  of  Women. — After  all,  we  must  re- 
member that  the  greater  number  of  women 
who  reach  old  age  never  consult  a  physician 
concerning  the  experiences  of  the  menopause. 
They  are  as  ignorant  of  the  significance  of  the 


ADVENT  AND  PROGRESS.  143 

cessation  of  the  menses  as  they  are  of  its  es- 
tablishment. It  is  fair  to  assume  that  with 
such  women  the  menopause  is  not  an  experi- 
ence of  serious  moment  or  one  in  which  ex- 
tensive information  would  be  of  any  particu- 
lar value. 

"  When  ignorance  is  bliss,  'tis  folly  to  be  wise." 

• 

THE  BEARING  or  FERTILITY  AND    STERILITY 
UPON  THE  MENOPAUSE. 

This  is  a  subject  of  no  little  importance, 
and  the  one  or  the  other  of  these  conditions 
is  often  the  characteristic  of  certain  families 
or  tribes. 

Fertility  and  Sterility  are  Relative  Terms. 
— It  must  be  remembered  that  these  terms 
have  a  relative  as  well  as  an  absolute  mean- 
ing, fertility  in  individuals  of  one  class  or 
type  not  being  applicable  to  those  of  another. 
There  is  also  a  sterility  which  is  relative 
and  one  which  is  absolute. 

In  the  case  of  a  rather  feeble,  poorly  de- 
veloped, physically,  inferior  woman,  the  bear- 
ing of  three  or  four  children  at  brief  intervals 


144  THE  MENOPAUSE. 

may  be  a  great  tax  on  her  vitality,  indeed  it 
may  be  a  strain  greater  than  her  vital  re- 
sources will  bear.  Another  woman  with 
robust  physique  and  great  vitality  may  bear 
a  dozen  children  in  as  many  years  without 
serious  detriment.  If  we  take  the  average  of 
women,  however,  it  is  very  much  the  same  as 
it  is  with  the  fruit  trees — a  period  of  bearing 
should  be  succeeded  by  a  period  of  rest.  If 
the  boughs  are  heavily  laden  with  fruit  year 
after  year  the  vitality  of  the  tree  will  soon  be 
exhausted.  Such  a  result  is  prevented  by 
the  off  years  in  which  little  or  no  fruit  is 
borne. 

Excessive  Fertility  may  hasten  the  Meno- 
pause.— With  many  women  the  bearing  of  six 
or  seven  children  in  rapid  succession,  lacta- 
tion being  almost  uninterrupted,  means  the 
exhaustion  of  the  reproductive  force,  and 
women  who  are  thus  excessively  fertile  prior 
to  the  thirtieth  year  usually  reach  the  meno- 
pause very  early. 

Excessive  fertility  in  women  of  weak  or 
depraved  constitution,  if  it  does  not  exhaust 


ADVENT  AND  PROGRESS.  145 

their  vitality  completely,  is  apt  to  lead  to  a 
premature  menopause,  even  though  there 
may  be  an  interval  of  two  or  three  years  be- 
tween pregnancies. 

Examples  of  this  are  women  with  phthis- 
ical tendency,  and  women  with  slender  phy- 
sique and  frail  constitution,  though  without 
deep-seated  disease.  Such  women  abound  in 
our  modern  society,  especially  in  the  cities, 
the  visible  evidence  of  false  ideas  in  the 
training  and  development  of  children.  Ill 
prepared  are  they  to  bear  the  strain  of  re- 
peated pregnancies,  especially  when  they  have 
in  addition  the  cares  of  a  household,  the  dis- 
sipations or  the  exactions  of  society  life,  and 
it  may  be  an  unreasonable,  selfish  husband. 
The  children  in  such  cases  are  too  often  puny 
and  short-lived,  and  a  premature  menopause 
to  the  mother  may  be  regarded  in  the  light 
of  a  blessing  and  a  relief. 

Prevention  of  Pregnancy  Warranted  in 
some  Cases. — It  would  seem  to  follow  from 
the  foregoing  that  with  some  women  preg- 
nancy under  any  circumstances  would  be 
11 


146  THE  MENOPAUSE. 

injudicious  and  undesirable.  This  is  un- 
hesitatingly admitted,  not  that  the  interrup- 
tion of  pregnancy  by  forcible  means  is  ad- 
vocated— far  from  it.  A  pregnancy  having 
begun  must  not  be  interfered  with,  except 
when  it  becomes  an  actual  menace  to  the  life 
of  the  mother.  But  when  the  conditions  in- 
volved are  a  delicate,  diseased,  badly  devel- 
oped woman,  with  not  enough  vitality  for 
her  own  use,  and  a  feeble,  puny,  imperfect 
child,  with  little  hope  or  prospect  of  being 
anything  but  a  burden  to  others  as  long 
as  it  may  live,  it  would  seem  logical  and 
reasonable  that  so  much  mischief  and  misery 
should  be  forestalled  either  by  the  avoidance 
of  marriage  on  the  part  of  the  woman  or  the 
avoidance  of  conception  if  marriage  is  in- 
sisted upon.  Fertility  in  such  individuals  is 
excessive,  under  any  circumstances,  and  is  to 
be  deprecated. 

Cliildbearing  no  Burden  to  many  Well- 
developed  Women. — With  the  woman  of 
grand  physique,  to  whom  childbeariug  is  no 
burden,  but  merely  the  accomplishment  of  a 


ADVENT  AND  PROGRESS.  147 

physiological  act,  the  response  to  one  of  the 
highest  impulses  of  their  nature,  the  meno- 
pause is  not  hastened  nor  in  any  way  un- 
favorably influenced  by  pregnancies  as  fre- 
quent as  Nature  will  permit.* 

Such  women  are  often  the  mothers  of 
heroes.  They  glide  into  pregnancy  and  labor 
and  out  again  with  little  discomfort,  taking 
up  the  thread  of  ordinary  life  again  with  lit- 
tle disposition  to  get  it  tangled,  menstruating 
perhaps  until  the  fiftieth  year  or  its  vicinity, 
and  experiencing  little  trouble  with  its  pass- 
ing away. 

Bearing  Children  a  Normal  Function  of 
Women. — With  regard  to  the  influence  of 
sterility  upon  the  menopause,  a  writer  has 
recently  said  that  from  a  physiological  stand- 
point the  great  object  for  which  woman  was 
created  was  to  reproduce  her  kind.  This 
seems  the  more  reasonable  when  we  realize 


*  The  author  reserves  as  exceptional  those  cases  already 
alluded  to,  in  which  repeated  pregnancies  and  lactation  in 
almost  uninterrupted  succession,  especially  in  young  women, 
exhaust  the  reproductive  force  and  hasten  the  menopause. 


148  THE  MENOPAUSE. 

that  a  decidua  or  nest  for  a  foatus  is  provided 
each  month,  only  to  be  shed  and  cast  off  in 
case  it  is  not  utilized  by  a  fertilized  ovum. 
From  a  physiological  standpoint,  therefore,  a 
sterile  woman  is  a  failure. 

Virgins  and  Married  Nulliparce. — There 
are  two  classes  of  such  women,  virgins  and 
married  nulliparae.  According  to  the  exist- 
ing status  of  civilized  society  the  former  are 
debarred  from  becoming  pregnant,  and  prop- 
erly so,  unfortunate  though  it  may  often  seem. 
to  be  from  the  before-mentioned  physiological 
standpoint.  The  latter  are  in  some  cases  in- 
tentionally and  willfully  sterile,  and  in  others 
the  sterility  is  due  to  deformity  or  defect  on 
the  part  of  the  woman  or  her  husband,  or 
both. 

It  would  seem  as  if  such  a  contravention 
of  physical  laws  *  must  be  followed  by  bad 
results  which  would  manifest  themselves,  par- 
ticularly in  connection  with  the  menstrual 


*  Of  course,  reference  is  made  exclusively  to  those  who 
are  physically  competent  to  conceive  and  carry  offspring  to 
term. 


ADVENT  AND  PROGRESS.  149 

function.  Such  a  result  does  occur,  and 
would  probably  occur  more  frequently  if 
women  led  merely  an  animal  life ;  fortu- 
nately, however,  the  cares  and  occupations 
which  come  to  most  of  them,  whether  single 
or  married,  divert  them  from  undue  attention 
to  such  subjects,  and  in  a  measure  compen- 
sate for  the  incomplete  accomplishment  of 
natural  functions. 

Course  of  Menstruation  and  the  Meno- 
pause in  the  Sterile. — With  the  sterile  a  pro- 
cess goes  on  which  is  analogous  to  the 
atrophy  of  structure  when  that  structure 
goes  long  unused  ;  the  recurring  congestions 
of  the  menstrual  epoch  fail  to  excite  those 
impulses  to  reproduction  which  are  excited 
in  those  with  whom  such  impulses  take 
their  natural  course,  and  the  menopause  is 
approached  and  experienced  without  any  un- 
usual phenomena  resulting  from  the  sterilty. 
With  those  who  have  preserved  their  vitality 
the  menses  may  suddenly  stop,  and  the  indi- 
viduals will  be  conscious  of  no  particular 
change  except  that  they  no  longer  have 


150  THE  MENOPAUSE. 

monthly   molimina    and    bleeding    and   that 
they  are  increasing  in  weight. 

In  occasional  instances  the  development 
of  a  serious  disease  settles  upon  them  like  a 
pall,  all  trace  of  the  monthly  sickness  disap- 
pearing in  the  general  breaking  up  of  Nature. 
In  others,  again,  there  are  the  same  pains  and 
aches,  with  infrequent  recurrences  of  the  flow, 
perhaps  an  occasional  metrorrhagia,  vasomo- 
tor  disturbances,  so  noteworthy  at  this  pe- 
riod, and  final  subsidence  in  the  quiet  of 
mature  life. 

5.  TEMPERAMENT,   HABITS,  OCCUPATION,  AND 
SOCIAL  SURROUNDINGS. 

Inherent  Tendencies  in  Individuals. — 
There  is  much  to  be  said  concerning  the  des- 
tiny or  fate  of  human  beings  on  the  side  of 
the  influences  which  are  fastened  to  them 
when  they  come  into  the  world.  Some  indi- 
viduals may  appear  to  shape  and  fashion  a 
portion,  at  least,  of  their  experiences  as  a 
helmsman  guides  a  ship.  But  this  may  be 
only  the  outward  appearance,  and  it  is  cer- 


ADVENT  AND  PROGRESS.  151 

tain  that  even  these  individuals,  heroes,  be- 
ings of  exceptional  strength,  are  at  times 
driven  irresistibly  by  forces  over  which  they 
have  no  control,  though  they  sometimes 
gain  control,  after  years  of  struggling  have 
elapsed,  by  that  process  of  adaptation  which 
so  often  adjusts  means  to  ends. 

There  are  also  Inherent  Tendencies  with 
Reference  to  Menstruation  and  the  Meno- 
pause.— It  is  the  same  with  the  functions  of 
the  body,  and  menstruation  with  the  meno- 
pause is  not  an  exception.  There  are  the 
unconscious  influences — those  with  which 
women  are  born,  the  family  and  race  pecul- 
iarities— the  intrinsic,  and  there  are  the  ex- 
trinsic, the  outward,  also  great  modifiers  of 
experience  which  may  be  useful  or  harmful, 
according  to  circumstances. 

Disposition  as  to  the  Individual  has 
much  to  do  with  the  Course  of  the  Meno- 
pause.— A  woman  who  is  endowed  with  a 
quiet  placid  temperament,  who  takes  the 
experiences  of  life  philosophically  and  with- 
out fret,  is  more  than  likely  to  pass  through 


152  THE  MENOPAUSE. 

the  menopause  peacefully,  provided,  of 
course,  that  there  is  no  intercurrent  develop- 
ment of  disease. 

It  is  the  nervous  and  hysterical  woman, 
the  one  whose  thoughts  and  sympathies  are 
centered  upon  herself,  who  has  a  hard  time 
at  the  menopause,  or  at  any  rate  she  thinks 
she  has. 

These  are  the  influences  of  inheritance 
(though  sometimes,  of  course,  they  are  due 
to  faulty  education,  to  want  of  restriction 
and  training  during  childhood  and  young 
womanhood),  the  conditions  to  which  we 
are  chained  when  being  begins,  and  they 
can  not  easily  be  shaken  off. 

Unfavorable  Experience  during  the  Men- 
strual Life  often  implies  a  Similar  Experi- 
ence during  the  Menopause. — As  to  outward 
influences,  those  who  have  had  a  stormy 
experience  in  general,  and  especially  those 
who  have  always  suffered  with  their  men- 
strual periods,  whether  from  pain,  excessive 
flowing,  or  irregularity,  are  prone  to  be  suf- 
ferers during  the  menopause.  We  should 


ADVENT  AND  PROGRESS.  153 

hardly  expect  anything  else  when  we  realize 
the  vascular  and  nervous  conditions  which 
attend  it. 

Irregular  and  Unwomanly  Occupation 
may  bring  an  Early  and  an  Uncomfortable 
menopause. — Those  whose  lives  have  been 
marked  by  excesses  of  various  kinds,  by  in- 
temperate use  of  alcohol,  by  sexual  vice,  by 
exhausting  labor,  by  bad  hygienic  surround- 
ings, are  very  apt  to  cease  menstruating 
early,  and  with  more  or  less  associated  pain 
and  other  trouble. 

Women  with  occupations  in  which  there 
is  exposure  to  great  atmospheric  changes, 
who  have  an  insufficiency  of  pure  air,  food, 
and  clothing,  often  reach  the  menopause 
early  in  life  and  with  no  little  discomfort. 
Such  are  workers  in  various  metals,  copper, 
phosphorus,  lead,  etc.,  fishwives,  women 
who  work  in  mines,  and  as  day  laborers  in 
the  streets  and  fields.  Surely  this  is  not 
woman's  work  or  we  would  not  see  such 
pitiful  spectacles  of  decrepit  and  wrinkled 
and  worn-out  creatures  at  a  period  when  the 


THE  MENOPAUSE. 

blusli  should  still  be  on  the  cheeks.  The 
great  hospitals  in  the  European  cities  are 
crowded  with  such  as  these. 

Effects  of  Occupation  upon  Cooks,  Laun- 
dress'38,  and  Others. — There  are  also  other  oc- 
cupations for  which  women  seem  to  have 
more  or  less  of  fitness,  but  which,  neverthe- 
less, produce  rather  striking  results  upon  the 
physical  condition,  and  results  which  are  not 
always  favorable.  Types  of  this  class  are 
furnished  by  cooks  and  laundresses — women 
who  work  many  hours  a  day  in  a  very  ele- 
vated temperature,  and,  in  the  case  of  cooks 
at  least,  are  constantly  inhaling  the  volatile 
portions  of  cooking  food.  Such  women  in 
many  instances  not  only  become  very  fat, 
but  suffer  greatly  with  menstrual  disorders 
(dysmenorrhcea,  oligomenorrhoea,  polynienor- 
rhcea)  ;  they  are  usually  sterile,  and  reach  the 
menopause  at  a  comparatively  early  period. 

One's  Trade  or  Occupation  may  be  the 
most  Potent  Factor  in  Determining  the  Meno- 
pause.— It  will  thus  be  seen  that  the  influ- 
ence of  one's  trade  or  occupation,  the  purely 


ADVENT  AND  PROGRESS.  155 

external  and  extrinsic  media,  may  be  a  most 
potent  factor,  perhaps  the  most  potent  factor, 
in  determining  the  time  and  the  mode  of  the 
menopause. 

SEXUAL  EXCESS  AND  ABSTINENCE. 

Very  Important  Subject. — This  is  a  sub- 
ject in  which  the  relation  to  the  menopause 
would  seem  to  be  so  intimate,  and  in  which 
there  is  so  much  material  for  thought  and 
consideration,  that  though  it  is  but  a  subdi- 
vision of  the  section  which  is  now  under  con- 
sideration, it  is  of  sufficient  importance  for 
particular  attention.  The  sexual  apparatus 
is  an  essential  portion  of  the  structure  of  the 
body — that  is,  the  body  is  incomplete  if  the 
sexual  apparatus  is  wanting. 

Imperious  Character  of  the  Sexual  Appe- 
tite.— The  sexual  appetite  is  as  appropriate  to 
an  individual  as  the  appetite  for  food.  In 
many  cases  it  is  quite  as  imperious  as  the 
appetite  for  food,  and  in  individuals  with 
whom  the  animal  part  of  their  nature  pre- 
dominates it  is  practically  uncontrollable. 


156  THE  MENOPAUSE. 

This  fact  explains  many  of  the  horrible 
crimes  which  have  been  perpetrated  upon 
helpless  women  and  defenseless  children. 
Excessive  indulgence  of  this  appetite  is  fol- 
lowed by  results  which  are  sometimes  dis- 
astrous. Complete  abstinence  is  probably 
followed  by  bad  results  in  some  cases,  but 
the  proportion  of  cases  in  which  injury  fol- 
lows denial  of  the  natural  inclinations  is  very 
much  smaller  than  that  in  which  those  in- 
clinations are  uncontrolled  and  unregulated. 
The  submission  of  the  material  side  of  an 
individual  to  the  spiritual  is  seldom  followed 
by  any  but  desirable  consequences. 

Sexual  Excess  and  the  Functions  of  the 
Genital  Apparatus  are  Relative  to  the  Indi- 
vidual Concerned. — To  fix  a  standard  as  to 
sexual  indulgence  or  to  define  sexual  excess 
is  extremely  difficult  and  will  not  be  at- 
tempted. It  must  always  be  relative  to  cer- 
tain conditions  inherent  in  the  individual 
concerned. 

The  same  is  true  concerning  the  func- 
tions, in  general,  of  the  uterus,  and  therefore 


ADVENT  AND  PROGRESS.  157 

in  one  case  menstruation  must  be  encouraged, 
in  another  repressed.  Childbearing  will  be 
a  blessing;  in  one  case,  in  another  a  bane. 

O  / 

Coitus  may  be  practically  unrestrained,  so 
far  as  tolerance  is  concerned,  with  one  wom- 
an, while  with  another  it  must  be  abstained 
from. 

If  we  were  to  consider  that  the  normal 
type  of  operation  as  to  the  sexual  functions 
exists  among  savages  who  are  living  in  the 
so-called  "  state  of  Nature,"  and  look  among 
them  for  the  best,  that  is,  the  most  natural 
results,  we  should  be  disappointed.  Those 
who  live  in  accordance  with  natural  appe- 
tites— that  is,  but  a  short  remove  from  the 
animals — do  not  present  the  best  results  from 
a  physical  standpoint. 

The  Best  Types  of  the  Sexual  Life  are  not 
to  be  found  among  Savages. — The  women, 
among  savages,  must  do  the  work ;  they  must 
yield  to  the  caprice  of  their  husbands'  appe- 
tites, whatever  be  their  own  physical  condi- 
tion ;  they  must  bear  and  look  after  the  chil- 
dren, and,  as  a  consequence,  they  are  worn 


158  THE  MENOPAUSE. 

out  relatively  early ;  their  sexual  organs  and 
proclivities  suffer  from  abuse  and  excess,  and 
they  become  old  and  wrinkled  when  those 
who  are  less  hardy  and  robust,  but  who  have 
been  more  rational  in  their  sexual  life,  are 
still  menstruating  and  capable  of  procreating 
healthy  offspring. 

We  should  learn  from  the  experience 
with  the  domestic  animals  that  when  women 
are  well  and  intelligently  treated  and  cared 
for  the  physical  results  will  be  better  in  all 
respects. 

Attempts  have  been  made  from  time  to 
time  to  reduce  the  question  of  sexual  indul- 
gence and  childbearing  to  scientific  limits. 

The  Experience  of  Stock  Breeders  sug- 
gests the  application  of  Similar  Principles 
among  Human  Beings. — In  view  of  the  ex- 
cellent results  which  are  attained  by  stock 
raisers  by  judicious  mating  and  crossing,  it 
would  seem  as  if  great  results  might  be  pos- 
sible in  the  begetting  of  children  by  the  ap- 
plication of  analogous  methods.  The  obsta- 
cles in  the  way  of  such  an  end  have  thus  far, 


ADVENT  AND  PROGKESS.  159 

however,  proved  insuperable,  individuals  in 
general  appearing  to  act  as  if  the  laws  which 
govern  and  control  reproduction  in  man  were 
different  from  those  which  affect  other  ani- 
mals. 

Concerning  the  Oneida  Community. — In- 
teresting in  this  connection  are  the  experi- 
ments which  have  been  made  by  different 
communities  of  socialists,  and  especially  in- 
teresting is  the  study  of  the  Oneida  Commu- 
nity of  socialists  which  was  made  a  few  years 
ago  by  Dr.  Ely  Van  de  Warker.* 

The  conditions  in  this  case  were  extreme- 
ly favorable  for  scientific  investigation,  for 
the  individuals  concerned  were,  for  the  most 
part,  occupied  with  healthful  duties ;  they 
had  good  hygienic  surroundings,  plenty  of 
food  and  clothing,  relief  from  the  ordinary 
worry  of  life,  and  freedom  from  the  dissipa- 
tion which  ordinarily  goes  hand  in  hand  with 
lives  of  sexual  indulgence. 

The  total  number  of  the  cases  which  were 
studied  is  small,  but  if  we  take  these  cases  as 

*  See  American  Journal  of  Obstetrics,  1884,  p.  785. 


160  THE  MENOPAUSE. 

fair  examples  of  that  which  might  usually 
occur  under  similar  conditions,  we  can  see 
that  abundant  sexual  indulgence  is  not  nec- 
essarily followed  by  unusual  experiences  at 
the  menopause.  The  theory  of  the  Oneida 
communists  was  that  sexual  intercourse  being 
the  response  to  a  natural  appetite  might  be 
indulged  in  until  the  appetite  was  satisfied, 
but  that  inasmuch  as  good  specimens  could 
be  reproduced  only  by  certain  types  of  indi- 
viduals, conception  was  to  be  prevented  ex- 
cepting in  selected  cases. 

Van  de  Warker's  table  contains  histories 
of  forty-two  women,  many  of  whom  were 
born  in  the  Community  or  were  placed  there 
in  early  life.  Sexual  intercourse  was  begun 
as  early  as  the  tenth  year,  and  was  followed 
by  the  early  appearance  of  the  menses.  In 
the  table  which  was  given  one  of  the  cases 
menstruated  at  ten  years,  eleven  at  twelve 
years,  and  twelve  at  thirteen  years. 

Among  thirty  of  the  childbearing  women 
only  eighteen  children  were  born  during  the 
communistic  life,  and  there  were  four  miscar- 


ADVENT  AND  PROGRESS.  161 

riages  which  were  not  artificially  produced. 
In  many  cases  sexual  intercourse  was  in- 
dulged in  seven  or  more  times  per  week,  some- 
times to  the  discomfort  and  displeasure  of 
the  women.  The  diet  of  the  women  was 
principally  a  vegetable  one.  They  com- 
plained little  of  the  pains  and  aches  from 
which  so  many  women  suffer,  and  there  were 
few  nervous  phenomena — in  fact,  the  health 
of  the  women  was  good. 

No  menstrual  derangements  were  com- 
plained of,  notwithstanding  the  excessive 
copulation.  The  average  age  for  those  who 
had  completed  the  menopause  was  48*7  years, 
the  number  who  had  passed  through  the  meno- 
pause while  living  in  the  Community  being 
eight.  It  was  unattended  by  any  unusual 
incident. 

The  Menopause  in  Prostitutes — The  sex- 
ual excesses  of  professional  prostitutes  and 
women  of  loose  character  in  general  might  be 
supposed  to  offer  a  profitable  field  for  re- 
search with  regard  to  the  consequences  of 

such  excesses  during  the   menopause.      The 
12 


1G2  THE  MENOPAUSE. 

results,  nevertheless,  are  disappointing,  how- 
ever true  the  general  statement  may  be  that 
irregular  living  and  the  practice  of  vice  find 
their  appropriate  physical  penalty. 

A  large  number  of  such  women  have  been 
under  the  professional  care  of  the  author 
from  time  to  time,  including  women  of  all 
ages,  all  degrees  of  prosperity  and  success,  as 
such  things  go,  and  all  grades  of  depravity. 
It  has  been  a  matter  of  constant  surprise,  in 
not  a  few  of  these  cases  (certainly  not  in  all 
of  them),  in  view  of  the  abuse  to  which  most 
of  them  subject  their  genital  organs,  as  well 
as  the  irregularity  of  their  lives  in  general, 
that  their  menstrual  history  differed  so  little 
from  that  of  women  who  live  virtuously  and 
respectably. 

Prostitutes  very  Susceptible  to  Disease.— 
This  does  not  mean  that  such  women  do  not 
acquire  disease ;  far  from  it,  for  sooner  or 
later  the  majority  of  them  do  acquire  syphilis, 
gonorrhoea,  or  both.  They  also  suffer  almost 
invariably  with  endometritis,  sometimes  with 
only  a  simple  catarrhal  discharge,  and  some- 


ADVENT  AND  PROGRESS.  163 

times  with  uterine  hemorrhage.  Pelvic  peri- 
tonitis is  very  common  among  them,  especially 
among  the  more  degraded,  who  are  less  care- 
ful and  particular  about  personal  cleanli- 
ness than  others,  and  by  whom  also  their  de- 
grading occupation  is  constantly  practiced, 
regardless  of  the  presence  of  menstruation, 
gonorrhoea,  syphilis,  or  anything  else. 

Certain  Diseases  very  Common  among 
Prostitutes. — The  fact  that  such  women  suf- 
fer extensively  from  venereal  disease  has,  of 
course,  been  recognized  from  time  imme- 
morial. The  particular  disease  of  the  tubes 
and  ovaries  which  results  from  the  infectious 
element  of  gonorrhoea  was  first  described  by 
Mercier  in  1849,  who  made  many  autopsies 
upon  prostitutes  in  Paris  and  discovered  this 
fact  in  the  course  of  such  labors.  The  fact 
has  since  then  been  verified  many  times  upon 
the  living  and  may  be  regarded  as  one  of  the 
most  common  consequences  of  a  life  of  prostitu- 
tion. This  disease  often  runs  a  very  prolonged 
course,  and  in  some  instances  has  been  known 
to  wear  itself  out  or  be  recovered  from  spon- 


164:  THE  MENOPAUSE. 

taneously.  Such  cases  have  been  seen  by  the 
writer,  and  the  pathological  phenomena  are 
analogous  in  some  respects  to  those  which  are 
often  seen  in  cases  of  tuberculosis  in  which 
the  disease  is  circumscribed  and  in  which 
the  products  undergo  degenerative  changes. 
These  cases  are  believed  to  be  rare,  however ; 
certainly  they  have  been  infrequent  in  the 
experience  of  the  writer. 

Serious  Disease  of  the  Genital  Organs 
may  result,  also  an  Early  Menopause. — The 
irregularities  of  a  prostitute's  life  are  such  as 
would  naturally  result  in  serious  disease  of 
one  organ  or  another,  the  general  resisting 
power  of  the  individual  being  also  weak- 
ened, and  these  conditions  doubtless  combine 
in  at  least  a  certain  portion  of  these  unfor- 
tunate individuals  in  abbreviating  the  men- 
strual life  and  bringing  on  an  early  meno- 
pause. In  spite  of  the  irregularities  and  ex- 
cesses of  such  a  life,  however,  there  are  some 
who  tolerate  such  conditions  with  no  ap- 
parent evil  consequence  from  the  physical 
standpoint.  The  shrewder  and  more  careful 


ADVENT  AND  PROGRESS.  165 

prostitutes  frequently  continue  their  business 
many  years,  and  some  of  them  save  consider- 
able amounts  of  money.  Some  of  them  marry 
and  have  children,  though  this  is  rare  for 
women  who  have  been  prostitutes  very  long, 
and  they  eventually  go  through  the  meno- 
pause with  an  experience  very  similar  to  that 
of  other  women  who  are  in  a  similar  physical 
condition.  They  sometimes  have  fewer  of 
the  uncomfortable  phenomena  of  the  meno- 
pause than  women  who  have  always  taken 
the  best  of  care  of  themselves. 

The  Experience  of  Prostitutes  sometimes 
contradicts  the  Results  which  would  ordi- 
narily be  expected. — To  predict  a  trouble- 
some menopause  for  a  woman  who  has  been 
guilty  of  such  sexual  excesses  as  would  rea- 
sonably warrant  such  a  prediction  is  not  in 
all  cases  in  accord  with  the  facts  of  experi- 
ence.* 

*  A  case  may  be  mentioned  of  a  woman  who  had  kept  a 
house  of  prostitution  thirty  years,  marrying  and  bearing 
children  in  the  meantime,  suffering  with  syphilis  and  vari- 
cose ulcers,  and  with  excessive  obesity,  but  otherwise  appear- 
ing to  lead  a  very  comfortable  life  physically.  Another 


166  THE  MENOPAUSE. 

Sexual  Abstinence  and  its  Relation  to  the 
Menopause. — The  opposite  view  of  this  sub- 
ject— that  is,  the  influence  of  complete  absti- 
nence from  sexual  intercourse  upon  menstru- 
ation and  the  menopause — could  best  be 
furnished  from  the  experience  of  such  a  com- 
munity as  that  of  the  Shakers,  with  whom 
the  custom  prevails  which  is  the  very  oppo- 
site of  that  which  is  characteristic  of  the 
Oneida  Community.  By  the  Shakers  sexual 
intercourse  is  regarded  as  wrong  and  to  be 
abstained  from  absolutely. 

Experience  of  ike  Shakers. — The  utmost 
pains  was  taken  to  procure  information  upon 
this  subject ;  the  Shaker  communities  through- 
out the  country  were  corresponded  with,  but 
all  requests  for  definite  information  were  de- 
clined. 

woman,  forty  years  of  age,  has  kept  a  house  of  prostitution 
or  has  been  associated  with  one  twenty-five  years.  She  had 
a  miscarriage  at  sixteen,  has  had  syphilis,  and  has  been  ad- 
dicted to  the  excessive  use  of  morphine  and  alcohol.  She 
appears  to  be  well  preserved,  says  she  has  no  trouble  with 
her  menstruation,  and  would  not  know  that  she  had  a  womb. 
Such  cases  might  be  multiplied  in  the  experience  of  the 
writer. 


ADVENT  AND  PROGRESS.  167 

Shakers  Noncommittal  concerning  the 
Sexual  Organs. — One  correspondent  stated 
that  subjects  relating  to  the  genital  ap- 
paratus were  not  to  be  thought  of,  still  less 
to  be  talked  about,  among  them.  The  only 
positive  information  that  could  be  obtained 
was  from  the  presiding  officer  of  one  of  the 
principal  communities,  who  stated  that  he 
knew  that  the  women  in  such  communities 
suffered  with  disorders  as  to  their  genital  ap- 
paratus and  as  to  their  menstruation,  but  to 
what  extent  he  was  unable  to  say.  He  re- 
ferred the  writer  to  the  superintendent  or 
principal  one  among  the  women  in  his  com- 
munity, but  she  declined  to  discuss  the  sub- 
ject. 

6.  ACCIDENTAL  INFLUENCES,  FEAE,  EMOTION, 
GRIEF,  ETC. 

Women  more  Sensitive  to  Impressions 
than  Men. — The  average  woman  is  at  all 
times  more  sensitive  to  impressions  than  the 
average  man,  and  there  are  certain  periods  in 
her  career  when  this  sensitiveness  is  intensi- 


168  THE  MENOPAUSE. 

fied ;  for  example,  when  she  is  menstruating 
and  when  she  is  pregnant. 

Sudden  Intense  Impressions  may  bring 
the  Menopause. — A  sharp,  sudden  impression 
would,  with  many  women,  check  menstrua- 
tion at  once,  and  with  not  a  few  women,  the 
pregnant  state  being  premised,  it  would  bring 
on  an  abortion.  Since  the  poise  in  such  mat- 
ters is  so  delicate  it  is  easy  to  understand 
that  an  impression  may  be  intense  enough  not 
only  to  check  an  existing  menstrual  flow,  or 
cause  the  uterus  to  throw  off  the  foetus  which 
it  contains,  but  to  produce  permanent  cessa- 
tion of  the  menstrual  flow  and  prevent  any 
subsequent  conception. 

These  Intense  Impressions  may  occur  at 
any  Time. — Such  a  result  may  be  accom- 
plished by  sudden  news  of  a  great  calamity, 
intense  fear,  apprehension  of  impending  ca- 
tastrophe, grief,  disappointment  in  love,  in- 
deed, the  entire  current  of  a  woman's  life 
may  be  changed  by  such  an  experience. 
Such  an  experience  may  occur  at  any  age, 
and  we  may  therefore  see  the  menopause  pro- 


ADVENT  AND  PROGRESS.  169 

duced  by  sudden  impressions  in  early  life,  at 
maturity,  or  at  a  time  when  in  the  natural 
course  of  events  the  menstrual  habit  would 
be  near  its  limit.  The  study  as  to  the  cause 
of  such  far-reaching  results  is  curious  and  in- 
teresting, but  it  belongs  especially  to  the  neu- 
rologist. It  is  strange  that  the  nervous  sys- 
tem should  so  dominate  the  body  as  to  control, 
by  an  influence  of  a  moment's  duration,  the 
entire  subsequent  channel  of  events  of  life. 

STATISTICS  WITH   REFERENCE   TO   CONDITIONS 
BEARING  UPON  THE  MENOPAUSE. 

Statistical  Data  bearing  upon  the  Meno- 
pause.— While  realizing  that  statistics  are  of 
uncertain  value,  since  they  can  be  twisted  to 
prove  almost  anything  or  to  prop  up  any 
statement,  no  matter  how  improbable,  it  has 
nevertheless  seemed  fitting  that  a  work  of 
this  character  should  not  be  entirely  void  of 
such  matter.  Such  statistics  as  are  presented 
are  offered,  therefore,  rather  with  the  idea 
that  the  reader  may  draw  such  inferences 
and  conclusions  as  may  seem  to  him  warrant- 


170 


THE  MENOPAUSE. 


able,  than  to  support  any  theory  which  the 
writer  may  have.  It  is  also  believed  that 
they  will  serve  as  a  fair  illustration  of  the 
conditions  which  attend  the  menopause  in 
our  heterogeneous  New  York  population. 
They  were  taken  from  the  records  of  the 
class  in  gynaecology,  for  the  past  few  years, 
at  the  Out-Patient  Department  of  Bellevue 
Hospital  in  New  York.  In  so  far  as  these 
data  have  a  bearing  upon  the  age  question 
of  the  menopause  they  have  already  been  in- 
troduced (see  pages  93-102).  They  are  here 
repeated  with  additional  specific  references 
upon  which  comment  will  be  appropriate. 


NATIVITY. 

Age. 

Children. 

Miscar- 
riages. 

Age  when 
menses  be- 
came irregu- 
lar or  ceased. 

Ireland  

52 

10 

o 

49 

54 

4 

2 

52 

50 

7 

3 

48 

51 

4 

0 

51 

50 

o 

1 

47 

50 

3 

1 

48 

50 

5 

1 

43 

47 

11 

5 

41 

45 

7 

0 

44 

44 

15 

1 

44 

37 

8 

1 

37 

43 

9 

0 

43 

46 

7 

o 

M 

46 

ADVENT  AND  PROGRESS. 


171 


NATIVITY. 

Age. 

Children. 

Miscar- 
riages. 

Age  when 
menses  be- 
came irregu- 
lar or  ceased. 

Ireland     

48 

10 

0 

48 

< 

47 

8 

2 

46 

48 

8 

1 

47 

45 

6 

4 

45 

40 

6 

2 

39 

49 

11 

4 

49 

40 

7 

1 

40 

48 

8 

0 

47 

40 

8 

2 

38 

40 

8 

2 

40 

40 

8 

4 

38 

42 

9 

0 

38 

56 

3 

0 

43 

51 

8 

3 

46 

47 

2 

0 

45 

44 

0 

0 

43 

46 

1 

6 

43 

60 

0 

0 

42 

28 

o 

1 

26 

48 

1 

0 

38 

43 

2 

1 

40 

39 

0 

0 

37 

38 

0 

0 

38 

38 

0 

0 

38 

40 

0 

0 

39 

50 

0 

0 

50 

42 

0 

0 

41 

50 

0 

1 

50 

44 

0 

0 

44 

50 

0 

0 

45 

41 

0 

0 

41 

45 

0 

0 

40 

45 

0 

0 

43 

48 

0 

0 

45 

58 

0 

0 

53 

50 

0 

0 

40 

40 

0 

0 

38 

52 

0 

0 

48 

United  States.  ... 

52 

3 

2 

50 

54 

5 

0 

46 

H 

52 

10 

1 

52 

(1 

55 

7 

8 

53 

II 

42 

6 

1 

41 

172 


THE  MENOPAUSE. 


NATIVITY. 

Age. 

Children. 

Miscar- 
riages. 

Age  when 
menses  be- 
came irregu- 
lar or  ceased. 

United  Stutes  

46 

13 

0 

46 

45 

17 

0 

45 

49 

10 

1 

48 

43 

6 

2 

42 

48 

6 

0 

48 

30 

7 

0 

30 

39 

8 

4 

37 

40 

7 

0 

40 

45 

0 

0 

44 

44 

0 

0 

44 

50 

0 

0 

48 

49 

0 

0 

48 

54 

0 

0 

48 

40 

0 

0 

40 

46 

0 

0 

46 

40 

0 

0 

40 

Polanrl  

43 

6 

4 

43 

Germany  

48 
54 

10 
10 

2 
0 

48 
46 

47 

8 

3 

47 

47 

9 

2 

45 

44 

8 

3 

44 

43 

0 

0 

42 

Italy.           ... 

46 

9 

1 

45 

45 

9 

1 

43 

Belgium  

52 

2 

3 

51 

England  

55 

15 

3 

48 

41 

0 

0 

39 

Denmark  

45 

0 

2 

45 

Total,  85. 

Excessive  Fertility  does  not,  of  Necessity, 
Precipitate  the  Menopause. — These  data  show 
that  excessive  fertility  does  not  necessarily 
precipitate  the  menopause,  one  woman  who 
had  borne  17  children  still  menstruating 
irregularly  at  the  age  of  45,  another  who 


ADVENT  AND  PROGRESS.  173 

had  given  birth  to  15  menstruating  at  in- 
tervals of  six  months  at  the  age  of  44,  and 
another  who  had  given  birth  to  13  menstru- 
ating at  intervals  of  seven  weeks  at  46. 

Of  these  85  cases  menstruation  ceased  or 
became  very  irregular  with  21  at  the  age  of 
40  or  less. 

Such  cases  as  the  one  in  which  the  meno- 
pause came  at  30,  after  the  birth  of  seven 
children,  are  instructive  and  illustrative  of 
the  exhaustion  of  the  reproductive  force  to 
which  allusion  has  been  made. 

In  the  case  in  which  the  menopause  oc- 
curred at  26  the  cause  of  this  early  appear- 
ance could  not  be  ascertained.  The  fore- 
going data  were  taken  from  the  records 
consecutively,  without  any  attempt  at  selec- 
tion. In  only  two  cases  was  there  any  ob- 
servation which  called  attention  to  serious 
disease,  one  of  them  being  a  case  of  malig- 
nant disease  of  the  uterus. 

Of  the  85  women  there  were  31,  nearly 
all  of  whom  were  married,  who  carried  no 
children  to  term,  and  only  three  of  whom 


1T4  THE  MENOPAUSE. 

had  ever  been  pregnant.  This  large  per- 
centage of  sterile  women  is  to  be  regarded 
only  as  an  incident,  for  the  percentage  in 
our  population  at  large,  whether  native 
or  foreign  born,  can  not  be  nearly  so  great  as 
this. 

Among  those  who  had  borne  children  1 
had  given  birth  to  17,  2  to  15,  1  to  13,  2  to 
11,  6  to  10,  5  to  9,  11  to  8,  7  to  7,  5  to  6. 
This  gives  the  large  average  of  9  to  40 
women.  Thus,  with  nearly  50  per  cent,  of 
the  cases  in  this  collection  in  which  there  is 
an  average  of  nine  children,  and  nearly  40 
per  cent,  in  which  there  is  an  average  of  nil, 
what  could  be  satisfactorily  proved  or  de- 
duced ? 

These  Statistics  are  admitted  to  be  of  no 
Great  Value  for  General  Deduction. — Even 
though  the  number  of  cases  considered  might 
be  very  much  larger,  it  is  doubtful  whether 
the  conclusions  one  might  draw  from  them 
would  be  altogether  safe  for  guidance,  and 
hence  such  a  method  of  arriving  at  the  an- 
swer of  questions  which  we  are  discussing 


ADVENT  AND  PROGRESS. 


175 


must  not  be  accepted  with  too  great  a  de- 
gree of  reliance. 

Of  the  cases  in  which  menstruation  was 
still  an  occasional  occurrence  at  intervals  of 
less  than  a  year  the  intervals  noted  were  1, 
2,  3,  4,  5,  6,  8,  and  10  months.  If  there  had 
been  no  recurrence  of  the  menstrual  flow  for 
a  year  or  more  it  was  assumed  that  the  men- 
strual function  had  terminated. 

A  series  of  134  cases  (including,  how- 
ever, many  which  are  in  the  foregoing  series) 
was  studied  with  reference  to  the  ailments 
which  caused  the  patients  to  seek  medical 
advice.  Those  conditions  which  were  most 
noteworthy  were  as  follows : 


AILMENT. 

No.  of 
cases. 

Age. 

No.  of 
chil- 
dren. 

No.  of 
miscar- 
riages. 

Urethral  irritation  

1 

55 

15 

3 

Endometritis  

1 

48 

4 

1 

Cardiac  lesion  

1 

50 

3 

1 

Rheumatism  

1 

50 

o 

3 

Perimetritis  and  cystitis  

1 

49 

3 

2 

Bronchitis  

1 

45 

o 

o 

Umbilical  hernia  

2 

(47 

11 

5 

Cystitis  

1 

(  78 
43 

0 
6 

0 
0 

Leucorrhoea.  . 

1 

40 

2 

0 

176 


THE  MENOPAUSE. 


AILMENT. 

No.  of 
cases. 

Age. 

No.  of 
chil- 
dren. 

No.  of 
miscar- 
riages. 

Lumbar  neuralgia  

5 

(48 

46 
1  50 

2 
0 
2 

0 
0 
1 

Occipital  neuralgia  

1 

145 
[30 
38 

2 

7 
0 

1 
0 
0 

Salpingitis  (Fallopian  tubes    re- 
moved, immediate  menopause). 
Gastric  catarrh  

1 
1 

45 
42 

4 
3 

1 

0 

Dyspepsia  .  .  , 

1 

54 

0 

0 

Anaemia  and  constipation.  .  .   . 

1 

38 

1 

0 

Nausea  and  tympanites  

1 

53 

0 

0 

Tvmpanites  

1 

40 

8 

2 

Dizziness  

1 

48 

3 

0 

Heat  flashes  

1 

37 

0 

0 

Heat  flashes,  dizziness,  and  dysuria 
Heat  flashes,  dizziness,  tympanites 

Intense  pain  in  head  and  abdomen 
Headache  and  palpitation  

1 
2 

1 

1 

44 
J43 
42 
43 
44 

3 
0 
9 
6 
0 

0 
0 
0 
4 
0 

Dysentery  

1 

(single) 
54 

5 

0 

Iliac   pain  and  purulent  vaginal 
discharge  

1 

45 

4 

1 

Lumbar  and  iliac  pain  and  leucor- 
rhoea    .                 

1 

45 

0 

0 

Iliac  pain,  flatulence   

1 

51 

4 

0 

Varicose  veins  

1 

40 

8 

2 

Metrorrhagia  (possibly  of  malig- 
nant origin,  menopause  at  45).  . 

1 

47 

9 

2 

In  this  table  are  35  cases  out  of  the  en- 
tire series  of  134  in  which  the  menopause 
had  been  completed  or  was  in  process  of  ex- 
perience in  which  the  ailment  complained  of 
was  of  sufficient  defmiteness  to  elicit  atten- 
tion in  the  clinical  histories  which  had  been 


ADVENT  AND  PROGRESS.  177 

taken.  In  only  one  of  them  was  there  a  sus- 
picion of  malignant  disease,  and  in  the  great 
majority  of  them  the  ailment  was,  in  all 
probability,  quite  distinct  in  its  origin  from 
the  menopause. 

Percentage  of  Malignant  Disease  very 
Small. — It  is  interesting  that  the  percentage 
of  malignant  disease  was  so  small,  and  if  it 
bears  any  particular  relation  to  the  subject 
which  is  under  discussion,  it  would  seem  to 
indicate  the  infrequency  rather  than  the  fre- 
quency of  malignant  disease  in  connection 
with  the  menopause.  As  a  matter  of  fact, 
statistics  aside,  we  know  that  malignant  dis- 
ease is  not  so  very  infrequent  in  the  decade 
from  40  to  50.  The  menopause,  however,  as 
has  been  already  remarked  on  several  occa- 
sions, has  little,  if  anything,  to  do  with  its 
causation.* 

The  Percentage  of  Cases  of  Disease  of  tlie 
Alimentary  Canal  is  Large. — In  about  25 


*  In  contrast  with  the  table  on  pages  175-176  the  follow- 
ing group  of  twenty-two  cases,   from  the  author's  private 
records,  shows  the  great  variability  of  statistics,  especially 
13 


178 


THE  MENOPAUSE. 


per  cent,  of  the  35  cases  analyzed  the  alimen- 
tary canal  was  more  or  less  implicated,  and 
in  more  than  40  per  cent,  the  nervous  system 
was  involved,  the  preponderating  phenomena 
being  pain  located  most  frequently  in  the 


when  the  numbers  of  cases  studied  are  small,  and  also  the 
futility  of  making  general  deductions  from  them.  The  per- 
centage of  serious  cases  in  this  group  is  very  large. 


NATIVITY. 

Age. 

Age  of 
meno- 
pause. 

cha- 

dren. 

Mis- 
car- 
ri'ges. 

Disease. 

United  States..  . 
Ireland  

46 
53 

40 
43 

2 
0 

2 

0 

Carcinoma  uteri. 
Myoma  uteri. 

United  States.  .  . 
German  v  

50 
42 
53 

45 
41 
45 

5 
0 
3 

1 
0 

1 

Cystoma  ovarii. 
Myoma  uteri. 
Carcinoma  uteri. 

United  States..  . 

H 

« 

M 

Germany  

54 
49 
53 
54 

48 

51 
46 
52 
51 

47 

3 

1 
? 

7 
5 

2 
0 

? 
0 
0 

Gall-stones. 
Kolpokleisis. 
Nephritis. 
Retroversio  uteri. 
Myoma  uteri. 

United  States..  . 
Ireland  

52 
45 
60 
54 

51 
43 
52 

48 

2 

0 
2 

7 

0 
0 

1 
o 

Osteosarcoma  sterni. 
Haematoma  lig.  br. 
Carcinoma  uteri. 
Tumor  abdominis. 

H 

50 

43 

2 

o 

Mvoma  uteri. 

M 

48 

47 

8 

0 

Menopause. 

M 

41 

40 

1 

o 

Carcinoma  uteri. 

• 

50 

48 

5 

0 

Carcinoma  uteri. 

United  States.  .  . 
Germany  

44 
50 
55 

38 
49 
53 

2 
6 
2 

0 
3 

o 

Salpingitis. 
Menopause. 
Cystoma  ovarii. 

Ireland  

50 

37 

2 

1 

Haemorrhoids         et 

1,010 

Average  age  at  the  menopause,  46  years. 


ADVENT  AND  PROGRESS.  170 

lumbar  region  and  vasomotor  crises — that  is, 
the  heat  flashes  to  which  multitudes  of  wom- 
en are  subject  at  some  time  or  other  during 
the  progress  of  the  menopause  with  varying 
degrees  of  discomfort.  Ten  of  the  35  wom- 
en, nearly  one  third,  had  been  sterile,  and 
only  one  had  never  been  married. 

Such  Statistics  not  Suited  for  formulat- 
ing a  Definite  Disease  of  the  Menopause. — 
From  these  statistics — and  they  have  been 
taken  without  any  attempt  at  selection — a 
fair  picture  may  be  made  of  the  phenomena 
which  may  accompany  the  menopause.  It 
would  evidently  be  impossible  to  build  up 
a  reasonable  theory  as  to  a  definite  disease  of 
the  menopause  from  such  or  similar  data. 
Not  a  few  writers  have  referred  to  "climac- 
teric disease "  as  if  the  experience  of  the 
menopause  might  include  a  distinct  patho- 
logical process.  It  is  hardly  necessary  to 
say,  after  what  has  already  been  said,  that 
in  the  opinion  of  the  author  no  such  patho- 
logical process  exists. 


180  THE  MENOPAUSE. 

THE  INFLUENCE  OR  BEAKING  OF  THE  MENO- 
PAUSE  UPON    OVULATION    AND    CONCEPTION. 

The  End  of  Menstruation  does  not  neces- 
sarily signify  the  End  of  Ovulation. — It  does 
not  follow  because  a  woman  has  ceased  to 
menstruate  that  ovulation  and  the  possibility 
of  conception  are  at  an  end,  not  even  though 
she  may  have  passed  through  many  of  the 
experiences  which  are  the  common  accom- 
paniments of  the  menopause,  and  which  are 
so  frequently  an  indication  that  fruitfulness 
no  longer  exists. 

Some  one  has  said  that  the  enormous 
number  of  ovules  in  an  ovary  was  an  argu- 
ment that  ovulation  continued  from  birth  to 
extreme  old  age.  Such  an  argument  without 
anatomical  basis  would  hardly  require  con- 
sideration. 

Ovulation  means  Exuberance  as  in  JVa- 
ture  in  General. — Prodigal  as  Nature  is  in 
the  supply  of  germs  of  this  character,  there  is 
apparently  the  same  allowance  for  waste  that 
is  seen  in  the  reproductive  elements  of  ani- 


ADVENT  AND  PROGEESS.  181 

mal  and  plant  life  in  general.  The  ultimate 
secret  or  reason  for  this  no  human  being  has 
found  out.  The  researches  of  Dalton,  which 
have  already  been  drawn  upon  for  an  earlier 
chapter,  throw  some  light  upon  the  subject, 
and  by  references  to  cases  quoted  in  Chapter 
II  we  see  that  the  condition  of  the  ovaries  as 
to  the  power  or  function  of  ovulation  varied 
much. 

The  absence  of  corpora  lutea  may  be 
considered  an  evidence  that  ovulation  has 
ceased. 

Details  from  Dalton's  Series  of  Cases  in 
Chapter  II. — In  case  II  of  the  series  referred 
to  a  patient  who  had  died  of  phthisis  pul- 
monalis  at  the  age  of  thirty-three,  after  an 
arnenorrhoea  lasting  six  months,  there  was 
contraction  and  cirrhosis  of  the  ovaries,  with 
few  remnants  of  Graanan  follicles  and  cor- 
pora lutea,  ovulation  and  the  reproductive 
force  being  nearly  obliterated. 

In  case  III,  in  which  death  came  at  the 
age  of  thirty  from  waxy  degeneration  of  the 
kidneys  and  disease  of  the  liver,  no  men- 


182  THE  MENOPAUSE. 

struation  having  occurred  for  eight  months 
prior  to  death,  the  ovaries  were  condensed 
and  atrophied  and  enveloped  in  old  adhe- 
sions. In  neither  ovary  were  there  healthy 
Graafian  follicles  nor  corpora  lutea. 

In  case  IV,  in  which  death  occurred  at 
twenty-one  from  cardiac  disease  and  pulmo- 
nary oedema  after  amenorrhoea  which  had 
lasted  ten  months,  there  was  atrophy  of  the 
ovaries,  no  corpora  lutea,  and  only  a  few 
small  Graafian  follicles.  Ovulation  had  ter- 
minated. 

In  case  V,  in  which  death  occurred  from 
meningitis  at  forty-three,  one  year  after  the 
last  menstruation,  there  were  no  normal 
Graafian  follicles  nor  corpora  lutea.  A  few 
degenerate  Graafian  follicles  had  evidently 
been  long  inactive.  The  meaopause  had  oc- 
curred at  the  proper  time  and  the  function  of 
ovulation  had  ceased  normally. 

In  case  VI,  in  which  death  came  at  fifty- 
five  from  abscess  of  the  liver  and  pneumonia, 
six  years  after  the  last  menstruation,  the 
ovaries  had  been  reduced  to  connective  tissue, 


ADVENT  AND  PROGRESS.  183 

with  nothing  to  indicate  that  ovulation  was 
possible. 

In  case  VII,  in  which  death  caine  at  forty- 
five  from  rupture  of  an  aneurism,  there  had 
been  only  one  menstrual  period  during  the 
last  year  of  life.  The  woman  had  borne  four- 
teen children.  The  ovaries  were  small  and 
contained  a  number  of  Graaiian  follicles,  but 
no  corpora  lutea.  The  follicles  showed  a 
tendency  to  collapse  before  maturity.  Ovu- 
lation had  probably  terminated. 

In  case  VIII,  in  which  death  occurred  at 
seventy,  the  ovaries  contained  a  few  collapsed 
Graafian  follicles,  but  no  other  evidence  of 
ovulation. 

In  a  case  which  was  attended  by  the  au- 
thor in  1890  the  patient  was  thirty-nine,  had 
borne  one  child  at  twenty-five,  and  otherwise 
had  never  been  pregnant.  She  was  operated 
upon  July  3,  1890,  for  pelvic  abscess  and 
peritonitis.  The  adhesions  in  the  pelvis  were 
dense  and  abundant,  the  right  ovary  had  dis- 
appeared, the  right  tube  was  a  mere  cord  of 
fibrous  tissue,  the  uterus  was  small  and  atro- 


184  THE  MENOPAUSE. 

phied,  the  left  tube  and  ovary  firmly  united, 
surrounded  by  adhesions  and  converted  into 
pus  sacs.  The  ovary  contained  neither  Graa- 
fian  follicles  nor  corpora  lutea,  and  there  had 
been  no  menstruation  for  three  months.  There 
was  no  tissue  in  which  ovulation  would  have 
been  possible. 

There  are  not  a  few  well  authenticated 
cases  in  which  conception  has  taken  place 
long  after  the  menopause  has  transpired,  and 
in  some  of  them  the  pregnancy  has  continued 
uninterrupted  until  term  and  delivery.  In 
others  an  abortion  at  an  early  month  showed 
that  the  reproductive  force  was  defective.* 

*  The  mother  of  an  esteemed  colleague  became  pregnant 
and  was  delivered  at  term  of  a  child  who  has  proved  in  his 
twenty  years  of  life  to  have  been  sufficiently  endowed  with 
vital  force.  Pregnancy  occurred  subsequent  to  the  fiftieth 
year,  several  years  after  the  menstrual  flow  had  ceased. 

A  case  is  recorded  in  a  recent  French  journal  (1892),  the 
particulars  of  which,  unfortunately,  can  not  be  given,  in 
which  pregnancy  occurred  at  fifty-nine.  Another  case  was 
narrated  to  the  author  by  a  colleague,  which  had  come  under 
his  personal  observation  and  attention,  in  which  there  was 
pregnancy  at  the  age  of  sixty,  which  continued  to  term,  and 
which  began  fourteen  years  after  the  menses  had  ceased.  Such 
instances  as  the  foregoing  are  not  isolated,  but  have  occurred 
to  many  observers  who  have  given  attention  to  such  matters. 


ADVENT  AND  PROGRESS.  185 

Ovulation  may  continue  after  Menstrua- 
tion has  ceased. — From  what  has  been  stated 
in  the  foregoing  pages  it  would  appear  prob- 
able that  in  the  great  majority  of  cases  the 
cessation  of  menstruation  signifies  the  termi- 
nation of  ovulation,  the  functional  power  of 
the  ovaries  having  reached  its  natural  limit. 
But  it  is  also  apparent  that  in  exceptional 
cases  ovulation  may  continue  after  menstrua- 
tion has  ceased,  perhaps  without  noticeable 
or  noteworthy  phenomena,  and  in  such  cases 
pregnancy  is  not  an  impossibility.  Should 
pregnancy  occur  the  evidence  would  be  prima 
facie  that  senile  degenerative  changes  in  the 
uterine  mucous  membrane  had  not  taken 
place,  for  if  the  formation  of  a  decidua  were 
impossible  the  development  of  a  fecundated 
ovum  would  be  equally  impossible. 

ADDENDA. 

OLIVE.  Menstruaciones  suplementarias ;  una  forma 
rara,  etiologia,  tratamiento.  Eevista  homeopatica. 
Barcelona,  1895,  vi,  329. 

STOCQUART.  Gas  de  cessation  tardive  des  regies. 
Archives  de  medecine  et  chirurgie  pratique.  Bruxelles, 
1890,  iv,  132. 


186  THE  MENOPAUSE. 

DRENTEL.  On  the  Climacteric  Age  of  Woman. 
Akuscherka  Briansk,  1892,  iii,  109. 

MULLER.  Influence  of  the  Climacteric  upon  Fibro- 
myomata.  Archiv  fiir  Gynakologie,  xl,  2. 

TAIT.  Myomata  of  the  Uterus.  Transactions, 
London  Obstetrical  Society,  xxv. 


CHAPTER  IV. 

THE  PHENOMENA  OF  THE  MENOPAUSE,  NORMAL 
AND  MOBBED,  AND  THEIR  DURATION. 

The  Typical  Menopause  a  Colorless,  Un- 
eventful Experience. — It  is  a  presumption 
which  would  seem  perfectly  reasonable  and 
warrantable  that  there  are  myriads  of  women, 
away  from  the  influence  of  doctors,  perhaps 
where  doctors  are  infrequent  or  inaccessible, 
who,  having  plenty  of  healthful  occupation 
and  little  time  or  inclination  for  musing  and 
brooding  over  physical  ills  and  ailments,  glide 
away  from  the  menstrual  function  and  men- 
strual life  with  as  little  disturbance  and  dis- 
comfort as  they  had  when  entering  it — that 
is,  they  are  conscious  of  nothing  amiss  in  re- 
spect to  this  portion  of  their  functional  ex- 
istence— and  such  women  constitute  the  type 

187 


188  THE  MENOPAUSE. 

of  that  which  the  menopause  ought  normally 
to  afford. 

Facility  in  obtaining  Medical  Advice  may 
exaggerate  the  Evils  of  the  Menopause. — 
How  large  the  number  of  such  women  may 
be,  who  can  tell,  for  it  is  not  the  well  who 
consult  the  physician,  but  the  sick  or  those 
who  think  themselves  sick.  On  the  other 
hand,  the  majority  of  women  who  attain  old 
age  under  the  eye  of  the  physician  have  more 
or  fewer  disturbances  and  annoyances  during 
the  years  which  mark  the  menopause,  such 
annoyances  varying  from  the  flashes  of  heat, 
followed  by  perspiration,  which  come  and  go 
without  warning  and  sometimes  without  ap- 
parent exciting  cause,  to  the  most  profound 
vascular  and  nervous  derangements. 

The  Normal  Menopause  not  a  Dangerous 
Experience  to  Life  or  Healtli. — The  position 
is  therefore  maintained  that  there  is  a  nor- 
mal— that  is,  an  uneventful — menopause,  and 
that  if  there  is  no  pre-existing  foundation  of 
disease,  the  menopause  should  not  be  consid- 
ered critical  in  the  sense  that  it  is  dangerous 


PHENOMENA  OF  THE  MENOPAUSE.   189 

to  life  or  health.  The  savage  and  the  aver- 
age woman  in  civilized  life  who  has  lived  out 
of  doors  or  who  is  of  an  insensitive  tempera- 
ment, knows  nothing,  as  a  rule,  from  expe- 
rience of  the  trials  of  the  menopause.  Does 
this  prove  the  superiority  of  the  savage  state 
or  the  state  of  Nature  from  the  physical 
standpoint  ? 

The  Civilized  preferable  to  the  Savage 
State. — It  would  perhaps  be  so  considered  if 
we  adopt  the  reasoning  and  admit  the  argu- 
ments of  writers  like  Rousseau ;  but  there  are 
compensations  in  civilized  life  for  the  ills 
which  may  accompany  the  menopause,  and 
this  compensatory  factor,  which  makes  civi- 
lized life  preferable  to  the  life  of  the  savage 
or  to  the  state  of  Nature,  does  not  seem  to 
have  been  appreciated  by  Rousseau  in  his 
writings  which  tended  in  this  direction,  nota- 
bly in  his  celebrated  essay  (Eniile)  on  edu- 
cation.* 


*  One  is  reminded,  in  this  connection,  of  the  remark 
which  has  been  attributed  to  the  late  Henry  Ward  Beecher, 
that  he  would  rather  be  an  unhappy  man  than  a  happy  flea. 


190  THE  MENOPAUSE. 

The  situation  has  been  admirably  covered 
by  Braxton  Hicks  in  the  Croonian  lectures 
for  1877,  and  with  his  usual  felicity  of  ex- 
pression:"* "After  the  change  is  completed 
the  system  improves,  the  many  irritations 
connected  with  menstruation  and  pregnancy 
are  gone,  and  the  changes  in  the  individual 
show  that  many  of  the  earlier  troubles  were 
functional  without  permanent  lesion.  The 
local  irritations,  engorgements,  and  fluxes,  all 
the  reflex  symptoms — neuroses,  vomiting, 
neuralgias,  headaches — gradually  pass  off." 

Phenomena  which  are  Common,  others 
which  are  Infrequent. — Perhaps  it  is  not 
strictly  correct  to  say  that  there  are  phe- 
nomena which  are  normal  to  the  menopause. 
There  are,  however,  phenomena  which  are 
common  and  others  which  are  less  common  or 
infrequent.  In  the  former  the  nervous  and  the 
vascular  systems  have  a  predominating  influ- 
ence. The  vasomotor  phenomena  are  pre-emi- 
nently conspicuous,  and  they  are  most  notice- 
able in  women  of  nervous  temperament. 

*  Medical  Times  and  Gazette,  1877,  i,  p.  411. 


PHENOMENA  OF  THE  MENOPAUSE.   191 

The  Individual's  Disposition,  whether  Sen- 
sitive or  Phlegmatic,  determines  in  a  measure 
the  Phenomena  of  the  Menopause. — It  is  but 
a  logical  consequence  that  women  who  dur- 
ing their  menstrual  lives  blush  furiously  at 
the  slightest  stimulus  of  one  character  and 
pale  at  an  equally  slight  stimulus  of  another, 
should  have  the  same  vasomotor  disturbances 
during  the  period  of  the  menopause  when  the 
equilibrium  of  the  forces  of  the  body  is  un- 
stable in  so  many  cases.  With  phlegmatic 
women  such  disturbances  are  less  common, 
and  even  should  they  occur  their  significance 
would  be  far  less  than  with  the  supersensi- 
tive  women  at  the  opposite  pole  of  tem- 
perament. 

Vasomotor  Phenomena  easily  excited. — 
The  origin  of  these  disturbances  may  be 
either  central  or  peripheral — that  is,  there 
may  be  an  exciting  cause  in  the  vasomotor 
centers  within  the  cerebral  cortex,  the  me- 
dulla, or  the  spinal  cord,  or  the  stimulus  may 
come  from  without,  the  peripheral  ends  of 
the  cutaneous  nerves  suffering  irritation. 


192  THE  MENOPAUSE. 

Works  on  neural  anatomy  and  neuro-pathol- 
ogy  should  be  consulted  for  the  special  pa- 
thology of  the  subject.* 

Vasomotor  Phenomena  due  to  an  Explo- 
sion of  Nervous  Force. — A  mental  sugges- 
tion, a  draught  of  wind,  a  sudden  emotion, 
violence  of  any  character,  or  possibly  a  cause 
of  which  the  patient  has  no  clew,  may  excite 
the  phenomena  in  question,  the  patient  being 
suddenly  conscious  of  an  explosion  of  nerve 
force,  a  flash  of  heat  about  the  face  and  head, 
and  a  minute  or  two  later  a  profuse  perspira- 
tion. In  some  cases,  at  least,  this  condition  of 
affairs  seems  kindred  to  the  aura  of  epilepsy, 
and  like  that  phenomenon  is  not  entirely  ex- 
plicable. It  frequently  leaves  the  patient 
rather  weak,  like  any  other  discharge  of 
nervous  force,  and  like  attacks  of  hysteria 
may  be  followed  by  a  copious  discharge  of 
limpid  urine. 

Manifestly,  both  cerebro-spinal  and   sym- 

*  A  very  good  consideration  of  the  subject  may  be  found 
in  Ross's  Diseases  of  the  Nervous  System.  Wood,  1883,  vol. 
i,  pp.  214-220. 


PHENOMENA  OF  THE  MENOPAUSE.  193 

pathetic  nerve  elements  are  involved,  and  in 
the  absence  of  any  satisfactory  explanation 
thus  far,  based  upon  exact  investigation,  it 
would  seem  possible  to  attribute  it  to  dis- 
turbance in  the  molecular  arrangement  of 
nerve  cells,  which,  it  must  be  admitted, 
is  but  a  meager  and  unsatisfactory  state- 
ment. As  the  menopause  progresses  this 
condition  may  recur  at  longer  and  yet  longer 
intervals,  gradually  fading  away  from  the 
experience,  or  it  may  continue  as  an  occa- 
sional visitor  to  the  very  end  of  life,  even 
when  life  is  prolonged  to  an  unusual 
limit. 

A  number  of  distinct  varieties  or  types  of 
this  condition  have  been  observed. 

1.  That  which  is  simplest  of  all,  manifest- 
ing the  heat  flash  which  comes  suddenly  and 
seldom  lasts  more  than  a  moment.     Its  modi- 
fications are  the  following : 

2.  Sweating. 

3.  Sweating  and  more  or  less  pronounced 
chill  or  shudder,  like  a  mild  paroxysm  of  ma- 
larial fever. 

u 


THE  MENOPAUSE. 

4.  Headache,   which   may   continue   long 
after  the  disappearance  of  the  heat  flash. 

5.  Melancholia  and  depression  or  mania. 

6.  Chilliness  of  the  extremities. 

7.  Abundant  discharge  of  urine. 

8.  Diarrhoea  and  congestion  of  the  pelvic 
organs,  with  the  addition,  in  some  instances, 
of  intense  sexual  ardor. 

These  Types  may  be  Distinct  or  they  may 
interllend. — These  several  types  may  be  clear 
and  distinct  or  they  may  interblend.  More- 
over, they  do  not  cover  the  entire  range  of 
phenomena  which  are  included  in  this  com- 
plex condition. 

GASTKO-INTESTINAL  DISTURBANCES. 

Less  frequent  than  the  vasomotor  disturb- 
ances, but  sufficiently  common,  and  the  source 
of  considerable  annoyance,  though  seldom  of 
any  real  danger,  are  the  gastro-intestinal  dis- 
turbances. As  they  have  been  observed  by 
the  author  they  may  be  mentioned  in  the  fol- 
lowing order  of  frequency : 

1.  Constipation. 


PHENOMENA  OF  THE  MENOPAUSE.  195 

2.  Intestinal  or  gastric  fermentation  with 
tympanites,  gurgling,  gulping,  etc. 

3.  Loss  of  appetite  with  indigestion  and 
the  usual  accompaniments  of  so-called  bilious- 
ness— viz.,   furred   tongue,   offensive   breath, 
muddy  skin,  scanty  and  light-colored  stools. 

4.  Diarrhoea. 

Troublesome  Phenomena  of  the  Meno- 
pause may  be  the  .Result  of  Previous  Bad 
Habits. — These  conditions  are  very  often  the 
result  of  the  bad  habits  or  indiscretions  of 
the  patients,  and  are  usually  quite  amenable 
to  treatment. 

It  would  be  strange,  indeed,  if  women 
who  have  all  their  lives  neglected  or  abused 
their  stomachs  and  bowels  should  go  through 
the  change  of  life  without  disturbance,  and 
troubles  of  this  character  will  sometimes 
serve  as  a  prelude  to  other  and  more  seri- 
ous ones  which  are  entailed  by  neglect  or 
improper  treatment.* 

*  The  disturbed  condition  of  the  alimentary  canal  with 
tympanites,  flatulence,  and  constipation  has  in  very  many 
instances  given  rise  to  a  suspicion  of  the  existence  of  preg- 


196  THE  MENOPAUSE. 


Ancemia  signifies  Poverty  of  tlie  Blood. 
—Closely  associated  with  the  vasomotor  and 
gastro-intestinal  disturbances  is  the  condition 
of  anaemia.  Anaemia  during  the  menopause 
does  not  necessarily  imply  great  losses  of 
blood  any  more  than  it  does  in  young  wom- 
en who  have  just  reached  or  just  passed 
puberty,  and  with  whom  it  is  of  common 
occurrence.  "What"  it  really  implies  is  pov- 
erty of  the  blood  in  red  corpuscles,  and  con- 
sequently in  haemoglobin,  iron,  and  oxygen. 
Of  course,  it  sometimes  signifies  profuse 
haemorrhages,  as  it  likewise  does  occasion- 

nancy,  and  this  has  sometimes  been  insisted  upon  by  the 
individual  who  was  the  subject  of  it,  until  such  insistence, 
unduly  prolonged,  became  ludicrous,  the  wish  being  father 
to  the  thought. 

Mary,  Queen  of  England,  wife  of  Phillip  II  of  Spain,  is 
said  to  have  been  deluded  by  such  a  misunderstanding  and 
miscalculation  as  the  foregoing. 

Unless  the  physician  is  entirely  on  his  guard  he  is  liable 
to  make  awkward  mistakes,  and  perhaps  be  held  heavily  re- 
sponsible in  cases  like  these.  Indeed,  ignorance  or  error  of 
diagnosis  in  times  like  the  present,  when  the  helps  and  means 
of  information  are  so  abundant,  is  not  creditable  and  often  is 
inexcusable. 


PHENOMENA  OF  THE  MENOPAUSE.  197 

ally  in  young  women,  and  it  may  also  be 
one  of  the  chain  of  symptoms  pointing  to 
the  presence  of  malignant  disease  in  the 
uterus  or  elsewhere;  but  in  the  experience 
of  the  author  this  has  been  a  somewhat  rare 
coincidence. 

The  Menopause  is  not  especially  Favor- 
able to  the  development  of  Malignant  Dis- 
ease except  in  those  who  are  predisposed  to 
it. — The  object  of  this  work,  to  a  degree  that 
is  earnestly  desired,  is  to  dispel,  if  possible, 
from  both  the  lay  and  the  professional  mind, 
the  idea  that  there  is  any  especial  danger  of 
the  development  of  malignant  disease  during 
the  menopause,  excepting  in  those  who  have 
a  predisposition  to  such  disease,  either  by 
heredity  or  by  virtue  of  a  depraved  condi- 
tion of  their  tissues  from  other  causes. 

HAEMORRHAGES    OF   THE    MENOPAUSE. 

Hcemorrhages  at  the  Menopause  formerly 
regarded  as  an  Essential  Accompaniment. — 
There  is  no  feature  of  this  subject  which  has 
given  rise  to  so  much  of  alarm  and  uncer- 


198  THE  MENOPAUSE. 

tainty  and  to  such  erroneous  conclusions  as 
this. 

It  has  already  been  stated  that  prior  to 
the  era  when  gynaecology  began  to  be  prac- 
ticed in  an  intelligent  and  reasonable  manner 
it  was  the  almost  universal  custom  to  con- 
sider haemorrhages  which  occurred  after  the 
childbearing  period  had  passed  as  necessary 
and  unavoidable,  and  this  false  notion,  it  is 
surprising  to  say,  still  prevails,  to  a  certain 
extent,  especially  with  the  older  generation 
of  practitioners.  This  haemorrhage  marked 
the  critical  time  and  would  cease  when  that 
time  had  passed,  or  it  might  result  in  cancer 
and  death.  What  its  cause  might  be  was 
usually  unknown,  and  very  little  was  done 
to  find  out  the  cause  or  to  overcome  it.  It 
was  in  this  way  that  the  ideas  concerning 
cancer  became  associated  with  those  which 
concerned  the  menopause. 

Such  Practice  counted  many  Victims. — 
The  relative  harmlessness  of  great  losses  of 
blood  during  the  menopause  was  an  article 
of  faith  which  was  a  suitable  accompani- 


PHENOMENA  OF  THE  MENOPAUSE.  199 

ment  to  that  doctrine  which  made  venesec- 
tion a  cardinal  principle  in  its  therapeutic 
system.  Such  erroneous  views  have  led  to 
the  sacrifice  of  untold  victims. 

We  in  these  later  days  can  appreciate 
heartily  the  pungent  wit  and  satire  of 
Moliere  in  E  amour  medecin  and  Le  malade 
imaginaire  as  we  think  of  the  bleeders,  pukers, 
and  purgers  of  his  time,  their  solemn  consul- 
tations, their  bombastic  rhetoric,  their  infinite 
complacency,  and  their  self-satisfying  conclu- 
sions. 

Of  course,  we  are  to  understand  by  the 
term  haemorrhage  in  this  connection  a  loss 
of  blood  far  in  excess  of  that  which  is  ordi- 
narily lost  at  the  menstrual  period,  for  only 
such  a  loss  would  excite  unusual  attention  or 
alarm. 

Haemorrhages  may  recur  at  Long  or 
Short  Intervals. — This  haemorrhage  some- 
times recurs  at  intervals  of  a  week  or  two, 
or  there  may  be  an  interval  of  one  or  sev- 
eral months.  If  the  intervals  are  long  there 
is  an  increased  formation  of  the  decidual  en- 


200  THE  MENOPAUSE. 

dometrium — that  is,  the  portion  which  the 
uterus  is  accustomed  to  shed — and  necessarily 
increased  vascularity.  The  breaking  down 
of  this  tissue  opens  up  an  unusual  number 
of  vessels,  and  favors  an  increased  outpour- 
ing of  blood.  If  the  intervals  are  short  the 
haemorrhage  may  be  due  to  increased  fria- 
bility of  the  endometrial  tissue,  as  Scanzoni 
has  suggested,  and  also  to  a  decided  increase 
in  that  impulse  by  which,  during  the  child- 
bearing  period,  the  blood  current  is  diverted 
to  the  pelvic  tissues. 

Conditions  Different  from  those  wliich  at- 
tend Ordinary  Menstruation. — The  condi- 
tions regulating  the  coagulability  of  the 
blood  are  also  different  from  those  which 
obtain  with  the  ordinary  product  of  the 
menstrual  period.  The  latter,  as  is  well 
known,  does  not,  under  the  usual  condi- 
tions, become  clotted,  being  influenced  by 
its  admixture  with  epithelial  detritus  and 
acid  glandular  secretion,  while  the  blood 
which  pours  from  the  uterine  vessels  in  the 
condition  under  discussion  is  often  coagu- 


PHENOMENA  OF  THE  MENOPAUSE.  201 

lated  like  blood  from  any  other  part  of  the 
body.  It  is  true,  however,  that  when  one 
has  been  weakened  by  frequent  haemor- 
rhages, and  the  blood  has  become  thin  and 
watery  in  consequence,  its  coagulating  ele- 
ments are  defective,  as  in  anaemia  under  any 
other  conditions. 

Such  Haemorrhages  demand  the  Relief 
which  Intelligent  Treatment  can  afford. — 
The  foregoing  remarks  apply  to  great  num- 
bers of  cases  in  which,  with  the  exception  of 
the  local  lesions  of  the  endometrium,  nothing 
of  a  morbid  character  can  be  detected.  It  is 
believed  that  it  is  eminently  unsafe  and  un- 
scientific to  leave  such  cases  to  Nature's  un- 
aided efforts  at  relief. 

The  necessity  for  the  thorough  investi- 
gation of  all  cases  is  seen  in  the  fact  that 
haemorrhages  may  be  due  to  disease  of  the 
endometrium  differing  from  that  which  has 
been  mentioned,  arising  from  myomata  of 
the  uterus  or  from  benign  or  malignant  dis- 
ease of  the  adnexa  or  other  structures  con- 
tiguous to  the  uterus. 


202  THE  MENOPAUSE. 

Scanzoni's  Theory  and  Objections  thereto. 
— Scanzoni's  theory  concerning  the  haemor- 
rhages of  the  menopause  is  that  they  are 
due  to  senile  rigidity  or  friability  of  the  en- 
dometrial  vessels  which  are  unable  to  stand 
the  blood  pressure.  Such  an  hypothesis 
might  be  sufficient,  as  has  already  been  ad- 
mitted in  some  cases,  but  would  not  be  of 
general  application.  A  morbid  process  of 
such  a  character  affecting  the  endometrial 
vessels  would  be  likely  to  affect  small  ves- 
sels elsewhere — for  example,  in  the  mucous 
membrane  of  the  nose — and  any  unusual  ex- 
ertion would  be  followed  by  their  rupture 
and  by  free  haemorrhage.  As  a  matter  of 
fact,  such  haemorrhages  have  not  been  ob- 
served to  be  of  especial  frequency  during 
the  menopause. 

KiscKs  Theory. — Kisch  attributes  the 
haemorrhage  to  softening  and  relaxation  of  the 
uterine  tissue  with  circulatory  disturbance  in 
the  pelvic  organs  and  obstruction  of  the  vena 
cava  ascendens,  stasis  in  the  vessels  of  the  uter- 
ine walls  and  haemorrhage  being  the  result. 


PHENOMENA  OF  THE  MENOPAUSE.  203 

Franks  Theory. — Frank  ventures  the 
opinion  that  the  haemorrhages  are  associated 
with  early  and  profuse  menstruation,  fre- 
quent and  difficult  labors,  frequent  abor- 
tions, and  excesses  in  drinking. 

Hegar^s  Theory. — Hegar  very  aptly  says 
there  is  an  absence  of  aetiological  factors  in 
some  of  these  cases.  Perhaps  it  would  be 
more  to  the  point  to  say,  in  such  cases,  that 
we  do  not  know  the  cause  of  the  trouble. 

Another  hypothesis  of  Hegars  is  that  the 
haemorrhage  is  due  to  diminished  pressure 
on  the  uterus  in  consequence  of  relaxed  and 
flabby  abdominal  walls  and  uterine  supports. 
But  in  how  small  a  number  of  cases,  relative- 
ly, does  this  exist !  Furthermore,  the  fatty 
degeneration  of  old  age  appears  usually  only 
after  the  menopause  is  concluded  and  the 
haemorrhages  have  ceased.* 


*  Borner  in  his  work  The  Menopause,  frequently  referred 
to  in  this  book,  has  quoted  the  foregoing  opinions,  and  the 
substance  of  them  has  been  borrowed  from  him. 


204  THE  MENOPAUSE. 

LESIONS  OF  THE  MIND  AND  NEEVOUS  SYSTEM 
IN  CONNECTION  WITH  THE  MENOPAUSE. 

Not  a  little  has  been  written  concerning 
the  influence  of  the  menopause  upon  the 
mind  and  nervous  system.  Cerebral  conges- 
tion is,  indeed,  not  an  uncommon  occurrence 
at  this  period,  and  may  be  due  to  the  diver- 
sion of  the  blood  current  and  to  the  fact 
that  pelvic  congestion  and  uterine  discharge 
no  longer  take  place  with  their  accustomed 
regularity.  But  cerebral  anaemia  is  also  of 
frequent  occurrence  at  this  period,  and  there 
may  be  present  a  great  variety  of  phenomena 
resulting  from  these  opposite  conditions. 

From  West  Riding  Asylum  Report.— 
Merson  has  observed*  that  epilepsy,  general 
paralysis,  or  atrophy  may  be  modified  dur- 
ing the  climacteric.  He  believed  that  the 
condition  of  nervous  irritability  in  connec- 
tion with  ovarian  changes  must  depend  on 
changes  in  the  blood  supply,  or  must  be 
due  to  a  change  of  nutrition  in  the  nervous 

*  West  Riding  Lunatic  Asylum  Report,  1876. 


PHENOMENA  OF  THE  MENOPAUSE.  205 

centers  which  arises  spontaneously,  or  else 
is  induced  by  influences  emanating  from  the 
reproductive  organs.  The  blood  supply  to 
the  brain  may  be  increased,  diminished,  or 
changed  by  retention  products  during  the 
climacteric.  Or,  if  the  cause  of  disturbance 
at  this  time  be  not  in  the  blood,  it  may  be  in 
the  ganglionic  centers,  influences  being  reflect- 
ed from  the  abdominal  ganglia  to  the  brain. 

Segals  Comments  on  the  Nervous  Phe- 
nomena of  the  Menopause. — Hegar*  refers 
to  one  hundred  and  twenty-six  paralyzed 
women  in  Meynert's  clinic,  in  nine  of  whom 
there  were  menstrual  derangements,  while  in 
sixteen  there  was  progressive  paralysis  which 
was  apparently  due  to  influences  connected 
with  the  menopause.  Hegar  likewise  thinks 
that  diseases  of  the  nervous  system  are  next 
in  frequency  to  those  of  the  sexual  organs 
during  and  after  the  menopause,  the  more 
prominent  symptoms  being  hyperaesthesia?, 
hyperkinesiaB,  prickling  and  burning  of  the 

*  Handbook  of  General  and  Operative  Gynaecology,  p.  291. 


206  THE  MENOPAUSE. 

skin,  dizziness,  pseudo-narcotism,  uncertainty 
in  walking,  muscular  weakness,  sleeplessness, 
hemicrania,  hallucinations,  etc.  The  halluci- 
nations may  be  of  hearing,  sight,  smell,  taste, 
or  feeling,  and  may  develop  into  progressive 
paralysis. 

Sexual  Ardor  of  the  Menopause. — In 
women  who  are  passing  through  the  meno- 
pause the  author  has,  in  some  instances,  ob- 
served sexual  ardor  in  connection  with  hallu- 
cinations and  other  nervous  phenomena. 

This  observation  is  probably  kindred  to 
that  which  has  been  made  by  Thomas,*  and 
in  which  attention  is  called  to  the  hysterical 
symptoms  (senile  hysteria)  accompanied  with 
tympanites,  which  symptoms  are  sometimes 
seen  in  those  with  whom  the  climacteric 
comes  unusually  late  in  life. 

Kischf  also  has  observed  and  commented 
upon  the  congestive  conditions  of  the  meno- 
pause which  are  associated  with  irritability 

*  Medical  Record,  December  6,  1879. 
f  Die  nervosen  Leiden  in  climakterischen  Alter.     Wiener 
Medicinischer  Presse,  1876,  xvii,  600,  644. 


PHENOMENA  OF  THE  MENOPAUSE.  207 

of  the  peripheral  nerves  and  with  sensitive- 
ness of  the  sexual  organs.  He  attributes  the 
somewhat  unnatural  marriages  which  occa- 
sionally occur  between  elderly  women  and 
young  men  to  such  causes. 

CLIMACTEEIC  INSANITY. 

Not  a  Definite  Type  of  Mental  Disease. — 
The  very  great  importance  which  attaches  to 
the  subject  of  lesions  of  the  mind  during  the 
period  of  the  menopause  has  suggested  a  par- 
ticular consideration  of  the  subject.  It  has 
even  been  proposed  by  a  number  of  writers 
to  dignify  this  condition  by  the  term  climac- 
teric insanity,  though  it  does  not  appear  that 
the  psychical  condition  is  such  as  to  establish 
a  distinct  type  of  mental  disease. 

Among  those  who  have  investigated  the 
subject  from  the  standpoint  of  the  alienist 
may  be  mentioned  Griesinger,  Esquirol, 
Krafft-Ebbing,  Guislain,  Schlager,  Skae, 
Merson,  Morel,  and  L.  Mayer. 

Griesinger  thinks  that  the  Melancholia  of 
the  Menopause  has  an  Unfavorable  Progno- 


208  THE  MENOPAUSE. 

sis. — Griesinger  was  of  the  opinion  that  psy- 
chical disease  was,  in  some  instances,  bene- 
fited by  the  experiences  of  the  menopause, 
but  that  in  a  greater  number  of  cases  it  was 
made  worse.  If  melancholia  developed  dur- 
ing the  menopause  he  was  accustomed  to 
give  an  unfavorable  prognosis. 

Tilt  has  recorded  430  cases  of  psychical 
disease  among  1,320  cases  in  which  the  phe- 
nomena of  the  menopause  were  analyzed. 
This  number  seems  quite  incredible  in  the 
light  of  ordinary  experience  with  the  phe- 
nomena of  the  menopause,  but  it  is  possible 
that  in  many  of  the  cases  the  psychical  dis- 
ease was  of  so  mild  a  type  as  to  be  over- 
looked by  any  except  an  unusually  keen 
observer. 

In  most  of  Skae's  Cases  the  Type  was 
Melancholia. — Skae's  opinion  is  that  climac- 
teric insanity  includes  an  important  natural 
group  of  conditions.*  An  analysis  was  made 
by  this  writer  of  200  cases  which  were  ob- 

*  Edinburgh  Medical  Journal,  1865,  x,  p.  703. 


PHENOMENA  OF  THE  MENOPAUSE.  209 

served  in  the  Royal  Asylum,  at  Edinburgh, 
and  in  which  the  age  of  the  greater  number 
of  the  patients  was  between  44  and  51.  In 
almost  all  the  cases  the  form  of  insanity  was 
melancholia,  and  in  107  of  them  it  was  very 
pronounced.  Depression,  insomnia,  listless- 
ness,  delusions,  suicidal  and  homicidal  im- 
pulse, though  the  latter  was  a  rare  occur- 
rence, were  noteworthy  symptoms,  and  most 
of  the  patients  were  asthenic,  anaemic,  and 
constipated.  Demonomania  was  a  common 
delusion,  also  fear  of  losing  the  soul.  The 
duration  of  the  disease  was  about  four 
months  in  most  of  the  cases,  the  recoveries 
amounted  to  53'5  per  cent,  the  deaths  to  10 
per  cent,  and  there  was  one  case  with  cancer 
of  the  uterus. 

Skae's  Conclusions.  —  The  conclusions" 
which  were  reached  by  Skae  were  as  fol- 
lows : 

1.  Climacteric  insanity  has  peculiar  fea- 
tures which  are  easily  recognized. 

2.  It  is  one  of  the  most  curable  forms  of 
insanity  in  which  melancholia  is  present. 

15 


210  THE  MENOPAUSE. 

3.  It  rarely  continues  longer  than   from 
three  to  six  months. 

4.  It  is  rarely  fatal  except  from  suicide  or 
when  associated  with  organic  disease. 

5.  The  patient  should  be  separated  from 
her  friends,  carefully  watched,  and  should  re- 
ceive suitable  diet  and  narcotics. 

Scene's  Opinion  concerning  Insanity  at 
the  Menopause. — Skene,  who  has  investigated 
the  question  of  climacteric  insanity  from  the 
standpoint  of  the  gynaecologist,*  is  of  the 
opinion  that  among  the  poor,  at  least,  this 
form  of  insanity  is  associated  with  bad  nutri- 
tion, which  has  also  been  accompanied  with 
frequent  childbearing  and  lactation.  His 
opinion  is,  furthermore,  that  this  form  of 
insanity  may  be  caused  by  organic  disease 
of  the  uterus,  or  that  the  presence  of  the 
latter  may  retard  recovery  from  the  insanity. 

Analysis  of  Conklin's  Cases. — Conklinf 
has  made  an  interesting  analysis  of  57  cases 

*  Archives  of  Medicine,  1880,  iii,  p.  1 
t  American  Journal  of  the  Medical  Sciences,  1871,  Ixii,  p. 
365. 


PHENOMENA  OF  THE  MENOPAUSE.  211 

which  were  under  his  care  at  the  Southern 
Ohio  Lunatic  Asylum.  In  25  of  the  cases 
there  was  hereditary  tendency  to  insanity, 
the  disease  progressing  gradually,  and  in 
some  cases  being  somewhat  badly  defined 
until  the  menses  had  entirely  disappeared. 
There  was  mania  in  5  of  the  cases,  there 
was  melancholia  in  41 ;  almost  all  the  cases 
showed  general  debility ;  there  was  suicidal 
tendency  in  26,  this  symptom  usually  ap- 
pearing early  in  the  morning  and  during 
the  period  of  convalescence.  There  were 
25  recoveries,  3  remained  in  the  asylum  in 
a  condition  of  dementia,  4  died,  and  the 
termination  in  15  remained  unknown.  With 
those  who  recovered  the  duration  of  the  dis- 
ease was  not  less  than  two  months  nor  more 
than  two  years. 

Sutherland^  Conclusions.  —  Sutherland 
has  summarized  the  relations  of  the  meno- 
pause to  insanity  clearly  and  tersely  as  fol- 
lows :  * 

*  British  and  Foreign  Medico-Chirurgical  Review,  i,  1874, 
p.  505. 


212  THE  MENOPAUSE. 

1.  Insanity   occurring   at   the   change   of 
life  is  not  usually  caused  by  that  condition 
per  se,  but  is  most  frequently  due  to  some 
other  moral  or  physical  cause  coincident  with 
that  period. 

2.  It  occurs  most  frequently  at  the  age  of 
forty -five  years  and  two  months. 

3.  Its  onset  is  usually  a  year  after  the 
cessation  of  menstruation. 

4.  The  married  state  does  not  predispose 
to  it. 

5.  Neither    does   the    number   of    labors 
which  a  woman  may  have  had. 

6.  It  takes  the  form  of  melancholia  oft- 
ener  than  mania. 

7.  Climacteric  insanity  has  certain  symp- 
toms which  are  characteristic. 

8.  The  prognosis  is  favorable,  more  than 
40   per   cent   of   the   cases   result    in   recov- 
ery. 

9.  Its  duration  is  usually  more  than  three 
months  and  less  than  three  years.     Complete 
recovery   seldom    takes    place   in   less    than 
twelve  months. 


PHENOMENA  OF  THE  MENOPAUSE.  213 

10.  The  treatment  should  consist  of  seda- 
tives, aperients,  and  watchfulness. 

Mer  son's  Conclusions. — Merson  has  al- 
ready been  alluded  to  in  connection  with 
this  subject,  and  his  excellent  contribution 
may  be  found  in  the  report  of  the  West 
Eiding  Lunatic  Asylum  for  1876.*  The 
following  data  were  taken  from  the  report 
in  question : 

During  a  given  period  of  four  years  392 
insane  women  between  the  ages  of  25  and 
40  were  admitted  to  the  West  E-iding  Asy- 
lum, and  333  additional  ones  between  the 
ages  of  40  and  55.  In  69  of  the  latter  in- 
sanity had  developed  prior  to  the  cessation 
of  menstruation,  while  in  147  it  developed 
during  the  progress  of  the  menopause. 

The  menopause  was  not  alone  responsi- 
ble for  the  insanity  in  these  cases,  addi- 
tional causes  being  present  as  follows : 

Cases. 

Bereavement  in 15 

Cruelty  on  the  part  of  the  husband 18 

Financial  trouble 5 

*  The  Climacteric  Period  in  Relation  to  Insanity. 


214  THE  MENOPAUSE. 

Cases. 

Fright 6 

Disappointment  in  love 2 

Remorse 3 

111  health  and  want 4 

Uterine  haemorrhage 4 

Fall  and  injury  of  the  head 3 

Fever  and  inflammation 4 

Intemperance 5 

Disease  of  the  heart 3 

Pulmonary  phthisis 4 

Organic  disease  of  the  brain,  not  related   to  the 

menopause 31 

In  the  147  cases  last  mentioned  90  were 
married,  33  single,  24  widows. 

With  43  a  tendency  to  insanity  was 
hereditary,  with  49  there  had  been  previous 
attacks,  with  13  there  had  been  recovery 
from  such  attacks  during  the  puerperal 
period. 

Excluding  cases  of  organic  brain  disease, 
Merson  divides  the  instances  of  climacteric 
insanity  which  he  has  analyzed  into  three 
groups,  as  follows : 

1.  Those  in  which  there  is  simple  depres- 
sion without  hallucination  of  the  senses  or 
intellectual  derangement,  and  in  which  nerv- 
ous irritability  and  hyperaBsthesia  are  also 
present. 


PHENOMENA  OF  THE  MENOPAUSE.  215 

2.  Those    in   which    there   is    depression 
with  emotional  and  intellectual  disturbance, 
also  hallucinations  and  delusions  of  a  depress- 
ing character. 

3.  Those  in  which  there  are  delusions  of 
suspicion  and   persecution,  hallucinations  of 
the  senses,  and  outbursts  of  excitement. 

Merson  differs  with  Bucknill  and  Tuke 
and  also  with  Vanderkolk  in  their  belief  that 
the  prognosis  of  this  condition  is  a  gloomy 
one.  In  his  147  cases  there  were  69  re- 
coveries. 

Rohe  *  has  observed  that  mental  disor- 
ders, especially  melancholia,  were  very  fre- 
quent between  the  ages  of  forty  and  fifty. 
With  the  degenerative  changes  in  the  sexual 
organs  which  are  to  be  found  in  such  cases 
there  may  also  be  associated  hallucinations  of 
hearing  and  smell,  religious  delusions,  also 
delusions  as  to  the  digestive  organs,  delusions 
of  grandeur,  and  pseudo-cyesis.  He  has  not 
been  able  to  satisfy  himself  that  there  is  any 

*  Climacteric  Psychoses.      Medical   Standard,    Chicago, 
1896,  xviii,  p.  69. 


216  THE  MENOPAUSE. 

period -in  the  life  of  men  which  corresponds 
with  the  menopause.  The  insanity  which 
sometimes  follows  removal  of  the  ovaries  is, 
in  his  opinion,  identical  with  climacteric  in- 
sanity, and  he  has  found  that  the  prognosis 
for  this  condition  was  favorable  in  40  to 
60  per  cent  of  all  cases. 

Matusch  *  has  found  that  the  two  critical 
phases  of  life  in  women  were  appropriate  for 
the  development  of  psychoses  and  hereditary 
and  degenerative  neuroses.  In  the  asylum  at 
Sachsenburg  there  were  551  insane  peasant 
women  who  came  under  his  observation,  and 
of  this  number  there  were  60  who  were  pass- 
ing through  the  menopause. 

Braxton  Hicks  f  calls  attention  to  the 
power  of  the  reflexes  from  the  uterus  and 
ovaries,  and  to  the  increased  sensitiveness  of 
woman  compared  with  man.  He  concludes 
from  this  that  woman  should  be  expected  to 
show  the  greater  tendency  to  mental  derange- 
ments and  disorders.  He  refers  also  to  the 

*  Allgemeine  Zeitschrift  fur  Psychiatric,  xlvi,  S.  4. 
t  Medical  Times  and  Gazette,  1877,  i,  p.  411. 


PHENOMENA  OF  THE  MENOPAUSE. 

statement  of  Mayer  that  among  six  thousand 
insane  women  and  girls  who  had  been  seen 
by  him  in  Berlin  there  was  a  percentage  of 
81 '03  in  which  menstrual  disorder  of  one 
character  or  another  was  complained  of. 

The  Mind  is  in  Unstable  Equilibrium  at 
the  time  of  the  Menopause. — The  foregoing 
evidence  shows  at  least  that  mental  and  nerv- 
ous troubles  play  an  important  part  in  the 
history  of  the  menopause.  This  relation  is  in 
many  cases  a  merely  accidental  one,  and  it 
does  not  appear  that  any  one  has  demon- 
strated or  even  tried  to  demonstrate  that 
there  were  specific  lesions  peculiar  to  the  in- 
sanity which  occurs  at  this  period.  Without 
doubt  the  mind  and  nervous  system  are  at 
this  time  in  a  state  of  unstable  equilibrium, 
as  was  observed  in  one  of  the  preceding  para- 
graphs, especially  in  the  case  of  nervous 
and  supersensitive  women,  and  it  is  easy  to 
understand  that  an  existing  lesion  might  at 
such  time  be  intensified  or  a  weak  mind  be 
thrown  entirely  off  its  balance. 

The  relations  of  the  ovaries  to  the  mental 


218  THE  MENOPAUSE. 

condition  were  at  one  time  supposed  to  be 
so  intimate  that  Goodell,*  Battey,  and  others 
anticipated  that  they  would  be  able  to  cure 
insanity  in  general  by  the  removal  of  those 
organs  irrespective  of  their  apparently  healthy 
or  diseased  condition. 

Such  theories  were  soon  found  to  be  futile 
in  practice,  and  the  theory  and  practice  were 
both  quickly  abandoned. 

Rohe  has  shown,  however,  by  a  not  in- 
considerable experience,  that  if  mental  disease 
coexists  with  decided  lesions  of  the  ovaries 
the  removal  of  the  latter  may  be  of  service  in 
relieving  the  former.f 

LESIONS  OF  THE  SKIN  WHICH  MAY  ACCOMPANY 
THE  MENOPAUSE. 

Common  Lesions  of  the  Skin  during  the 
Menopause. — There  are  certain  well-marked 
lesions  of  the  skin  which  are  of  common  oc- 

*  Transactions  of  the  Pennsylvania  Medical  Society,  1881, 
xiii,  Part  II,  p.  638. 

f  For  further  testimony  upon  this  interesting  question 
one  may  refer  to  Braxton  Hicks,  Medical  Times  and  Gazette, 
1877,  i,  p.  411;  Barnes,  Lancet,  1,  1873,  p.  585. 


PHENOMENA  OF  THE  MENOPAUSE.  219 

currence  in  the  history  of  the  menopause. 
The  blushing  or  erythema  which  comes  and 
goes  so  frequently  and  mysteriously,  and 
which  has  already  been  referred  to  with  suffi- 
cient definiteness,  may  be  considered  the  most 
striking  member  of  this  group,  while  less 
noteworthy  is  the  pronounced  pallor  which  is 
observable  in  the  anaemic  cases. 

Rohe's  *  observations  upon  this  subject 
are  of  great  interest  and  demonstrate  the 
great  variety  of  skin  affections  which  may  oc- 
cur while  the  menopause  is  in  progress. 

Pigmentation,  etc. — Grelletyf  reports  a 
peculiar  case  in  which  dark  pigment  discol- 
ored the  entire  cutaneous  surface  of  a  woman 
of  fifty-seven  whose  menses  ceased  at  fifty- 
five,  the  exudation  into  the  skin  apparently 
taking  the  place  of  the  customary  menstrual 
flow.  The  same  author  has  observed  pseudo- 
lipomata,  chronic  oedema,  and  numerous  erup- 
tions indicating  disturbance  of  the  circulation. 

*  American  Journal  of  Obstetrics,  1888,  p.  1094. 
t  Wood's  Medical  and  Surgical  Monographs,  vol.  Hi,  July, 
1889,  p.  1. 


220  THE  MENOPAUSE. 

Martineau  *  lias  also  observed  deposits  of 
pigment  and  glandular  disorders,  chloasma, 
etc. 

Similar  phenomena  have  been  observed 
and  recorded  by  Kaposi,  Brett,  Cazenave, 
Hardy,  Guibout,  Rayer,  Leroy  de  Meri- 
court,  Grisolle,  and  Brierre  de  Boismont. 

Eczema  Genitalium. — Deligny  is  quoted 
by  Grellety  f  as  responsible  for  the  opinion 
that  eczema  genitalium  was  almost  peculiar 
to  the  menopause. 

Such  an  opinion  does  not  correspond, 
however,  with  the  experience  of  the  author, 
this  disease  having  been  observed  by  him  at 
nearly  every  period  of  life,  as  well  when  the 
menses  were  present  as  when  they  were  sup- 
pressed or  had  been  superseded.  It  has  been 
observed  by  him  many  times  in  a  very  aggra- 
vated and  troublesome  form  in  old  women 
many  years  after  the  cessation  of  the  men- 
strual now. 

Skin  Lesions  upon  the  Breasts. — The  skin 

*  Diseases  of  the  Uterus,  p.  104. 
f  Concours  Medical,  April  14,  1888. 


PHENOMENA  OF  THE  MENOPAUSE.  221 

upon  the  breasts  is  occasionally  the  seat  of 
most  annoying  pruritus  during  the  progress 
of  the  menopause,  and  neuralgia  or  mastodyn- 
ia  may  be  associated  with  it.  Paget's  dis- 
ease of  the  nipple  may  begin  at  this  period  of 
life,  but  in  most  cases  it  comes  at  a  more  ad- 
vanced age. 

In  addition  to  the  foregoing  there  is  quite 
a  mass  of  other  literature  which  is  devoted 
to  this  subject,  which  has  been  contributed  by 
Alibert,  Danlos,  Jacquemier,  Courty,  and 
Potain. 

Lesions  of  the  skin  may  therefore  be  re- 
garded as  among  the  essential  phenomena  of 
the  menopause,  though  it  is  important  to 
differentiate  those  which  are  closely  asso- 
ciated from  those  which  are  merely  acci- 
dental. 

LESIONS  OF  OTHER  PARTS  OR  ORGANS. 

Incidental  Relationships  to  the  Meno- 
pause.— It  will  be  evident  from  the  foregoing 
remarks  that  the  relation  between  the  meno- 
pause and  diseases  of  the  nervous  system  and 


222  THE  MENOPAUSE. 

the  skin  is  often  very  intimate,  and  the  rela- 
tionship must  be  closely  studied  in  order  to 
conduct  the  menopause  to  the  most  favorable 
issue  possible. 

There  are  other  lesions  in  which  the  rela- 
tionship to  the  menopause  is  not  so  intimate, 
in  which,  moreover,  it  is  apparently  acci- 
dental or  incidental,  but  in  which  it  is  also 
sufficiently  prominent  to  excite  attention  and 
call  for  consideration  in  connection  with  this 
discussion. 

In  a  previous  chapter  this  matter  has 
been  alluded  to  in  some  of  its  bearings. 
Asthenopia  has  been  occasionally  observed  in 
women  who  were  passing  through  the  meno- 
pause, these  women  having  been  free  from 
this  trouble  prior  to  the  menopause,  and  ex- 
periencing relief  from  the  same  when  the 
menopause  was  terminated. 

Higgins  *  has  reported  nine  such  cases  in 
women  between  the  ages  of  forty-four  and 
fifty. 

*  British  Medical  Journal,  1878,  ii,  p.  557. 


PHENOMENA  OF  THE  MENOPAUSE.  223 

Stolz  *  has  recorded  his  observation  of 
the  peculiar  tendency  of  women  passing 
through  the  menopause  to  vomiting,  dyspep- 
sia, jaundice,  constipation,  haemorrhoids,  rheu- 
matism, asthma,  and  bronchitis. 

Cardiopathies. — Cardiopathies  are  of  fre- 
quent occurrence  during  this  period,  as  might 
be  expected  in  view  of  the  vascular  lesions 
which  are  so  common,  and  which  have  been 
referred  to  heretofore. 

While  there  is  no  particular  reason  for 
supposing  that  lesions  de  novo  are  excited  by 
the  processes  which  are  in  course  of  develop- 
ment, there  is  ground  for  the  belief  that  pre- 
existing lesions  are  sometimes  intensified, 
somewhat  as  is  the  case  during  pregnancy, 
though  not  from  the  same  causes  and  condi- 
tions, of  course. 

Clement  f  divides  the  Cardiopathies  of  the 
menopause  into  two  groups  : 

1.  Those  which  exhibit  all  the  symptoms 

*  Nouveau  Dictionnaire   de  Medecine  et  de    Chirurgie 
Pratique,  sub  Menstruation, 
t  Lyon  Medical,  1884,  p.  433. 


224  THE  MENOPAUSE. 

of  profund  perturbation  of  the  cardiac  func- 
tion with  no  physical  signs  of  valvular  le- 
sions. 

2.  Those  in  which  there  are  signs  of  val- 
vular trouble,  which  is  first  seen  during  the 
menopause  and,  as  Clement  believed,  under 
its  influence. 

In  none  of  the  cases  which  has  been  seen 
by  the  author  was  there  previous  history 
of  heart  disease  or  rheumatism.  The  promi- 
nent symptoms  in  these  cases  were  palpita- 
tion, dyspnoea,  syncope,  and  weak  pulse,  the 
latter  running  from  150  to  160  beats  per 
minute. 

These  symptoms  recurred  in  paroxysms. 
Similar  phenomena  have  been  observed  by 
Kisch,  Groedel,  Moon,  and  Stokes.* 

Tachycardia  has  been  observed  by  Bald- 
win^ and  he  believes  this  symptom  is  espe- 
cially liable  to  occur  when  the  menopause  is 
artificially  induced. 

Other  Lesions  which  are  probably  attribu- 

*  Diseases  of  the  Heart  and  Aorta. 

t  Brooklyn  Medical  Journal,  1895,  ix,  p.  698. 


PHENOMENA  OF  THE  MENOPAUSE.   225 

table  to  Old  Age. — In  addition  to  the  lesions 
referable  to  the  heart  there  have  been  ob- 
served in  the  cases  which  are  under  con- 
sideration an  increase  in  the  excretion  of 
carbonic  acid,  deposits  in  the  urine  of  phos- 
phates, carbonates,  sulphates,  and  uric  acid, 
ptyalisin,  diarrhoea,  an  engorged  portal  circu- 
lation, and  jaundice.  If  this  series  of  symp- 
toms may  seem  somewhat  incoherent,  it  is 
vouched  for,  nevertheless,  by  some  of  the 
most  distinguished  observers  of  the  last  gen- 
eration. 

Other  lesions  which  have  been  attributed 
to  the  influences  of  the  menopause,  but  which 
would  seem  to  the  author  to  be  due  rather 
to  the  degenerative  changes  which  accom- 
pany the  onset  of  old  age,  are  atrophy  of 
the  spleen,  the  lymphatics,  Peyer's  patches, 
thickening  of  the  boundaries  of  the  lymph 
spaces,  etc. 

Changes  in  glandular  activity  in  general 
may  be  expected  at  this  period  of  physical 
development,  increased  activity  being  soon 
followed  by  a  diminution  of  the  same. 

16 


226  THE  MENOPAUSE. 

From  the  kidneys  more  uric  acid  and 
phosphates  are  eliminated,  and  albuminuria 
may  be  present  without  necessarily  imply- 
ing serious  lesion  of  the  kidneys. 

Increased  Susceptibility  to  Disease  at  the 
Menopause  calls  for  Increased  Watchfulness 
on  the  part  of  the  Physician. — The  function 
of  the  lungs  may  also  be  deranged.  In  a 
word,  while  it  is  quite  possible  that  a  woman 
may  pass  out  of  the  childbearing  period  with 
no  symptoms  which  could  disturb  her  or  give 
her  serious  inconvenience,  it  is  equally  pos- 
sible that  during  the  same  period  she  might 
be  the  subject  of  a  great  variety  of  troubles. 
These  troubles  are  not  necessities,  inevitables, 
but  they  are  seen  with  sufficient  frequency 
among  civilized  and  highly  bred  women  to 
make  it  incumbent  upon  the  careful  physician 
to  keep  a  watchful  eye  upon  his  patients  who 
are  approaching  the  menopause,  and  to  re- 
member the  increased  susceptibility  to  dis- 
ease which  accompanies  that  period. 


PHENOMENA  OF  THE  MENOPAUSE.     227 

ADDENDA. 

GROS.  Rheumatism  at  the  Menopause  and  cure 
with  the  Waters  of  Lamalou  1'Ancien.  Nice  Medical, 
1883-'84,  viii,  17-22. 

GUENAU  DE  MUSSY.  Erotism  of  the  Menopause. 
Clinique  Medical,  Paris,  1875,  ii,  343-352. 

IVANOFF.  On  the  Great  Number  of  Cases  of 
Dropsy  and  Jaundice  during  the  Period  of  the  Change 
of  Life.  Voyenno-med.  Journal  of  St.  Petersburg, 
1883,  cxlvii,  pp.  3,  62,  92. 

JAGGARD.  Functional  Disorders  in  connection 
with  the  Menopause.  Pepper's  System  of  Practical 
Medicine.  Philadelphia,  1886,  iv,  432-446. 

BAX.  Cessation  des  regies  et  sueur  de  sang  chez 
une  hysterique.  Gazette  des  hopitaux  de  Toulouse, 
1895,  ix,  274. 

MANTOST.  Note  on  Menopausal  Polysarcia  Ab- 
dominalis.  Medical  Age,  Detroit,  1895,  xiii,  420. 

OLLIVE.  The  Menopause,  its  Complications  and 
Treatment.  Texas  Medical  Journal,  Austin,  1895-'96, 
xi,  9. 

BLOOM.  Physiological  and  Surgical  Menopause 
compared.  University  Medical  Magazine,  Philadel- 
phia, 1895,  viii,  342.  . 

ROHE.  The  Mental  Disturbances  of  the  Climac- 
teric Period.  Maryland  Medical  Journal,  1895,  xxxiv, 
258. 

KISCH.  Die  Herzbeschwerden  klimakterischen 
Frauen.  Berliner  Klinischer  Wochenschrift,  1889, 
xxvi,  1087. 

CONKLIN".  Some  Neuroses  of  the  Menopause. 
Transactions  of  the  American  Association  of  Gynas- 


228  THE  MENOPAUSE. 

cologists  and  Obstetricians,  Philadelphia,  1889,  ii, 
301. 

NELSON.  The  Beginning  of  the  Menopause. 
Medical  and  Surgical  Reporter,  Philadelphia,  1890, 
Ixii,  507. 

JOAL.  Sur  certains  Phenomenes  de  la  Meno- 
pause d'Origine  genito-nasale.  Congres  International 
d'Otologie  et  de  Laryngologie,  Paris,  1889,  347. 

KRISHABEK.  Hemorrhagie  Linguale  a  1'Epoque 
de  la  Menopause.  Annales  des  Maladies  de  1'Oreille, 
du  Larynx  et  des  org.  com.,  Paris,  iii,  38. 

KISCH.  Ueber  Tachycardie  zur  Zeit  der  Meno- 
pause. Internationale  Klinische  Rundschau,  Wien, 
1891,  xvi,  337. 

COE.  Pelvic  Suppuration  after  the  Menopause. 
American  Journal  of  Obstetrics,  1893,  xxvii,  421. 

GARAT.  Influence  de  la  Menopause  sur  la  De- 
veloppement  de  la  Folie.  Paris,  1892,  G-.  Steinheil, 
pp.  103. 

ELIOT.  Disorders  of  the  Nervous  System  Asso- 
ciated with  the  Change  of  Life.  American  Journal 
of  the  Medical  Sciences,  1893,  cvi,  292. 

SAVAGE.  Some  Mental  Disorders  associated  with 
the  Menopause.  Lancet,  1893,  ii,  1128. 

CAMPBELL.  Flushing  and  Morbid  Blushing.  Lon- 
don, Lewis. 

GEBER.  Anomalien  der  Schweissdriisen  und  ihrer 
Function.  Ziemssen's  Handbuch  der  speciellen  Pa- 
thologic und  Therapie.,  xiv,  Heft  2. 

RICORD.  Etude  sur  les  Troubles  de  la  Sensibilite 
genesique  a  1'Epoque  de  la  Menopause.  Paris,  pp.  45, 
1879. 

UNITED    STATES    CENSUS,    1890.     Statistics    of 


Women  who  became  Insane  during  the  Decade  from 
Forty  to  Fifty. 

PAGES.  De  la  Menopause  et  de  son  Influence  dans 
la  Production  de  1'Alienation  Mentale.  Paris,  1872. 

WERTH.  Entstehung  von  Psychosen  im  Gefolge 
von  Operationen  am  weiblichen  Genital  apparate.  Ver- 
handlungen  des  Deutschen  Gesellschaft  fiir  Gynakolo- 
gie.  Zweiter  Congress,  1888. 

BRUANT.  De  la  Melancolie  survenant  a  la  Meno- 
pause. Gazette  Medicale,  February  14,  1891,  p.  81. 

WILLETTE.  Etude  sur  les  Accidents  Nerveux  de 
la  Menopause.  Paris,  1877. 

EXGELMANN.  The  Hystero-neuroses.  Transac- 
tions of  the  American  Gynaecological  Society,  ii,  483, 
and  xiii,  332. 

HEGAR.  Der  Zusammenhang  der  Geschlechts- 
krankheiten  mit  Nervosen  Leiden  und  die  Castration 
bei  Neurosen.  Stuttgart,  1885. 

KISCH.  Die  Nervosen  Leiden  der  Frauen  im  Kli- 
makterischen  Alter.  Wiener  Medicinische  Presse,  1876, 
xvii,  600. 

PETIT.  The  Relations  of  General  Paralysis  in 
Women  to  certain  Disorders  of  Menstruation.  Gazette 
Medicale,  February  23,  1889. 


CHAPTER  V. 

THE  PEEMATUEE  MENOPAUSE. 

Definition. — By  this  term  is  meant  that 
variety  or  form  of  the  menopause  which  takes 
place  more  or  fewer  years  in  advance  of  the 
time  when  it  would  be  expected  to  occur  as  a 
natural  and  looked  for  experience.  It  is  im- 
material to  our  present  purpose  whether  this 
end  is  accomplished  with  or  without  the  in- 
tervention of  art. 

Great  Importance  of  ih#  Subject  resulting 
from  the  Development  of  Q-ync&cology. — The 
development  of  the  science  of  gynsecology  has 
given  this  feature  of  our  subject  an  impor- 
tance and  interest  which  it  never  had  before. 
It  has  opened  entirely  new  fields  for  observa- 
tion and  discussion,  and  while  it  is  true  that 
the  menopause  often  occurred  prematurely 
before  it  came  to  be  produced  artificially  and 

230 


THE  PREMATURE  MENOPAUSE.    231 

intentionally,  it  seems  to  have  excited  little 
attention,  and  its  relations  to  the  normal  pro- 
cess were  seldom  if  ever  made  a  matter  for 
thoughtful  consideration  and  comment. 

Premature  Menopause  Unnatural. — The 
premature  occurrence  of  the  menopause  is 
unnatural,  and  is  therefore  the  evidence  or  the 
result  of  disease  or  fault. 

Like  the  Natural  Process  its  Phenomena 
vary. — It  may  resemble  the  natural  process 
in  that  no  noteworthy  incident  may  accom- 
pany it ;  again  it  may  show  all  the  vagaries 
which  are  encountered  when  the  menopause 
comes  at  the  time  of  life  when  it  is  usually 
looked  for.  Temperament  and  surroundings 
have  much  to  do  with  it,  just  as  they  have 
with  the  mature  process. 

Involvement. — The  disease  which  will  in- 
duce the  early  occurrence  of  the  menopause 
may  be  constitutional  or  local ;  it  may  involve 
primarily  the  nervous  system,  the  vascular 
system,  the  lungs,  the  kidneys,  the  glands, 
the  genital  apparatus  collectively,  or  only  a 
portion  of  the  latter.  Climate  has  a  potent 


232  THE  MENOPAUSE. 

influence  in  the  matter,  so  have  heredity, 
habit,  and  function. 

Effective  Causes. — Those  who  live  in  the 
tropics  and  mature  early  reach  the  menopause 
early  also,  though  this  rule  has  many  excep- 
tions. The  same  causes  are  not  always  similarly 
effective  in  producing  the  end  in  question — 
in  other  words,  the  individual  factor  in  the 
case  is  an  important  one. 

Menstruation  often  Independent  of  In- 
tegrity of  the  Ovaries. — It  is  often  a  matter 
of  astonishment  that  the  sexual  organs  in 
women  can  be  so  thoroughly  diseased  with- 
out producing  the  termination  of  the  men- 
strual function,  and  sometimes  without  even 
disturbing  its  regularity.  It  is  certainly  an 
evidence  that  menstruation  is  not  necessarily 
dependent  upon  integrity  of  the  ovarian 
stroma,  perhaps  not  upon  the  stroma  at  all, 
for  its  continuance  or  termination,  the  nexus 
being  in  all  probability  in  the  vascular  and 
nerve  relationships. 

Influence  of  Wasting  Diseases. — Pre-emi- 
nent among  the  constitutional  disorders  and 


THE  PREMATURE  MENOPAUSE.          233 

derangements  which  cause  an  early  meno- 
pause may  be  mentioned  the  wasting  diseases, 
and  of  these  tuberculosis  is  first  in  impor- 
tance. There  are  some  tuberculous  women 
who  have  never  menstruated  at  all ;  there  are 
others  who  are  regular  at  the  beginning  of 
their  menstrual  history,  and  when  the  disease 
gets  well  under  way  either  stop  menstruating 
abruptly  or  after  a  series  of  irregular  recur- 
rences. 

Amenorrlicea  may  be  Conservative. — It  is 
useless  to  try  and  restore  the  menstrual  func- 
tion in  such  cases.  It  is  often  attempted,  es- 
pecially because  the  patients  are  wont  to  be- 
lieve that  with  its  restoration  will  come  an 
improvement  in  their  general  condition.  This 
idea  is  entirely  erroneous,  the  cessation  of 
bleeding  being  an  attempt  on  the  part  of  Na- 
ture to  ameliorate  the  condition  of  those  who 
have  no  blood  to  spare. 

Various  factors  which  induce  Prema- 
ture Menopause. — An  early  menopause  is  also 
not  infrequent  with  those  whose  lives  have 
been  irregular  and  characterized  by  excesses 


234  THE  MENOPAUSE. 

of  various  kinds,  like  prostitutes,  with  those 
who  have  suffered  from  poverty,  or  whose 
lives  have  been  embittered  by  grief,  sorrow, 
or  disappointment.  Other  causes  are  syphilis, 
the  amyloid  disease  (Klob),  various  poison- 
ous substances,  phosphorus,  alcohol,  arsenic, 
opium,  mercury,  and  ergot,  acute  diseases  in- 
cluding typhus,  typhoid,  intermittent,  remit- 
tent, and  yellow  fevers,  septicaemia,  and  the 
acute  exanthemata. 

Excessive  sexual  indulgence  will  likewise 
hasten  it. 

The  foregoing  are  conditions  in  which  a 
relation  of  time,  at  least,  coexists  with  the 
menopause ;  the  relation  of  cause,  evident  in 
some  cases,  is  not  clearly  demonstrable  in  all. 

It  may  be  affirmed,  however,  that  in  so 
far  as  these  conditions  impair  nutrition  they 
tend  to  produce  the  result  in  question,  the 
blood  current  in  the  pelvic  region  being 
feeble  in  volume  and  tension. 

Obesity  induces  the  Menopause. — Another 
class  of  women  with  whom  the  menopause 
comes  early  includes  those  who  are  very  fat. 


THE  PREMATURE  MENOPAUSE.          235 

This  has  not  been  generally  recognized  in 
medical  writings,  but  has  been  observed  by 
the  author  many  times.*  Fat  women  are 
physically  inferior  in  many  respects :  they 
suffer  with  scanty  and  painful  menstruation, 
and  they  are  very  often  sterile. 

Premature  Menopause  in  tlie  Excessively 
Fertile. — Women  who  begin  to  bear  children 
early,  and  have  five,  six,  or  more  in  rapid  suc- 
cession, often  have  an  early  menopause.  The 
reproductive  force  in  such  cases  is  exhausted. 
This  is  especially  noteworthy  in  women 
whose  lives  are  monotonous — with  continued 
and  severe  labor.  Kisch,  Kriiger,  and  Mayer 
have  made  the  same  observation.  (See  also 
Chapter  III,  page  136.) 

Venereal  Diseases  causing  the  Meno- 
pause.— Diseases  which  involve  the  integrity 
of  the  genital  organs  may  hasten  the  meno- 
pause. Mention  has  already  been  made  of 
syphilis  and  excessive  sexual  indulgence ; 

*  See  author's  paper  on  The  Influence  of  Obesity  on  Men- 
struation and  Reproduction  in  Young  Women.  Medical 
News,  1888,  p.  172. 


23G  THE  MENOPAUSE. 

to  these  should  be  added  gonorrhoea,  which 
is  responsible  for  a  very  large  portion  of  the 
severe  inflammatory  disease  of  the  entire 
genito-urinary  apparatus. 

General  Condition  of  the  Nutrition  one  of 
the  Principal  Factors  in  Menstruation. — It  is 
the  depraved  nutrition  of  the  body  in  general 
rather  than  the  local  disease  itself,  be  it  of 
the  uterus,  tubes,  or  ovaries,  which  hastens 
the  menopause,  for,  as  has  already  been  re- 
marked, the  ovaries  may  be  entirely  disor- 
ganized, as  far  as  their  normal  structure  and 
relations  are  concerned,  the  tubes  may  be 
mere  sacs  of  pus  or  dense  masses  of  connec- 
tive tissue,  and  the  uterus  may  be  entirely 
transformed  as  to  the  structure  of  its  endome- 
trium,  so  that  the  formation  of  a  decidua 
would  be  impossible,  and  yet  menstruation 
may  continue  without  interruption. 

PREMATURE  MENOPAUSE  RESULTING  FROM 
TRAUMATISM. 

Menopause  from  Injuries. — Of  course  it 
is  possible  that  injuries  may  be  received  in 


THE  PREMATURE  MENOPAUSE.          237 

various  parts  of  the  body — wounds,  bruises, 
etc. — the  influence  of  which  may  be  reflected 
to  the  pelvic  organs  and  determine  the  cessa- 
tion of  the  menstrual  function.  Especially 
would  this  be  possible  if  such  injury  were 
followed  by  prolonged  illness,  prolonged  sup 
puration,  or  wasting  and  emaciation. 

Menopause  from  Sequelce  of  Parturition. 
— There  are  also  not  a  few  cases  in  which 
the  menopause  results  in  consequence  of 
severe  injuries  attending  parturition ;  for  in- 
stance, cases  in  which  labor  has  been  pro- 
longed, and  sloughing  and  loss  of  tissue  have 
resulted,  or  in  which  the  same  results  have 
followed  severe  obstetrical  operations.  Those 
cases  are  less  frequent  than  they  used  to  be, 
thanks  to  the  benign  influence  of  modern 
gynaecology,  for  the  development  of  that  sci- 
ence has  necessitated  development,  pari  passu, 
in  the  science  and  art  of  obstetrics. 

Menopause  surgically  induced. — The  trau- 
matisms  to  which  especial  attention  is  in- 
vited are  those  which  are  intentionally  pro- 
duced by  the  surgeon  upon  the  uterus,  tubes, 


238  THE  MENOPAUSE. 

or  ovaries,  or  all  of  them,  with  the  knowledge 
and  often  with  the  desire  that  the  menopause 
should  result. 

This  aspect  of  our  subject  was  not  con- 
sidered by  Tilt  and  others  who  have  written 
upon  it,  for  the  very  good  reason  that  such  a 
short  cut  to  the  menopause  was  never  heard 
of  by  them. 

Jfegar,  Battey,  and  Tail. — It  is  a  chapter 
in  the  history  of  surgery  which  reflects  the 
greatest  credit  upon  three  names — Hegar, 
Battey,  and  Tait— and  has  been  the  means 
of  conferring  health  and  happiness  upon 
thousands  of  suffering  women.  These  three 
names  are  referred  to  in  particular,  because 
these  men  saw  the  inestimable  advantages 
which  were  to  be  obtained  by  certain  suf- 
fering women  if  the  menopause  were  in- 
duced, while  the  handful  of  ovariotomists, 
including  McDowell,  Clay,  Keith,  Wells, 
Peaslee,  Baker  Brown,  Sims,  and  a  few 
others,  did  their  noble  work  solely  or  main- 
ly with  the  idea  of  saving  life.  All  honor 
to  them  for  their  genius,  their  skill,  their 


THE  PREMATURE  MENOPAUSE.          239 

humanity,  which  often  produced  their  grand 
results  in  defiance  of  persecution  and  oblo- 
quy, and  finally  disarmed  their  opponents 
through  the  unimpeachable  testimony  of  a 
great  cloud  of  witnesses  rescued  from  dis- 
ease and  death ! 

CLAIMS  OF  BATTEY  AND  HEGAK  AS  TO  PEIOK- 
ITY  IN  SUGGESTING  THE  ARTIFICIAL  PttO- 
DUCTION  OF  THE  MENOPAUSE. 

The  idea  of  the  inestimable  value  of  the 
induced  menopause  occurred  to  Battey  in  this 
country  and  Hegar  in  Germany  independent- 
ly of  each  other  and  at  about  the  same  time. 

Hegar  states*  that  he  performed  his  first 
castration  f  July  27,  1872,  for  the  relief  of 
intolerable  dysmenorrhoea  and  ovarian  neu- 

*  Handbook  of  General  and  Operative  Gynaecology.  Cy- 
clopaedia of  Obstetrics  and  Gynaecology,  vol.  vi,  p.  294. 

t  The  Germans  use  this  ungainly  term  to  signify  the  opera- 
tion for  removal  of  the  ovaries.  Etymologically  it  may  be 
correct  enough,  for  it  means  cutting  or  pruning.  Pliny  was 
the  first  to  use  the  term,  so  far  as  can  be  ascertained,  and  it 
does  not  appear  that  Pliny's  use  of  it  when  applied  to  animals 
differs  from  that  to  which  we  are  accustomed,  namely,  the  re- 
moval of  the  testicles. 


240  THE  MENOPAUSE. 

ralgia,  his  patient  dying  of  septic  peritoni- 
tis. Battey's  first  operation  was  performed 
August  17,  1872,  his  express  purpose  being 
the  induction  of  the  menopause. 

Influence  of  the  different  Genital  Organs 
in  the  Induction  of  the  Menopause. — In  the 
majority  of  cases  the  removal  of  the  ovaries 
is  sufficient  to  produce  the  menopause.  Tait 
laid  great  stress  upon  the  importance  of  the 
simultaneous  removal  of  the  tubes ;  but  Bat- 
tey,  who  carefully  followed  for  many  years 
the  clinical  history  of  the  women  upon  whom 
he  operated,  found  no  advantage  in  such  re- 
moval as  far  as  its  influence  in  producing  the 
menopause  wTas  concerned.  In  some  cases,  es- 
pecially those  in  which  troublesome  tumors 
of  the  uterus  were  present,  the  menopause  has 
not  resulted  until  the  uterus  was  removed. 

INDICATIONS  FOR  THE  ARTIFICIAL  PRODUCTION 
OF  THE  MENOPAUSE. 

Cases  for  Induction  of  the  Menopause 
should  he  selected  with  Great  Care. — Battey 
has  well  said  that  there  is  need  of  the  great- 


THE  PEEMATUEE  MENOPAUSE.    241 

est  care  in  the  selection  of  cases  for  the  pro- 
duction of  the  menopause  if  the  existence  of 
extensive  lesions  in  the  uterus  or  its  append- 
ages is  wanting.  Doubtless  very  many  mis- 
takes have  been  made  in  this  particular  by 
men  of  good  intentions,  and  the  lines  are  not 
yet  so  clearly  drawn  as  to  enable  one  to  say 
precisely  what  cases  require  or  will  be  bene- 
fited by  operation  and  what  ones  will  not. 
The  table  of  indications  which  is  given  is 
therefore  provisional  and  may  require  modi- 
fication. 

1.  All  cases  in  which  there  is  extensive 
inflammatory  disease  of  the  ovaries  or  tubes, 
or  both.  If  the  tubes  are  removed  the  ova- 
ries should  be  removed  also,  for,  the  tubes 
having  been  removed,  the  functional  power 
of  the  ovaries  is  practically  destroyed.  If  a 
portion  of  ovarian  tissue  seems  intact,  it  will 
be  better  practice  in  the  majority  of  cases, 
notwithstanding,  to  remove  the  entire  organ. 
Resection  ,has  been  advocated  and  practiced 
by  numerous  gynaecologists,  but  disease  is 

prone  to  recur  in  the  fragment  which  was 

17 


24-2  THE  MENOPAUSE. 

retained   and   a  secondary  operation   is   fre- 
quently required. 

2.  All  cases  in  which  the  ovaries  or  tubes 
are  the  seat  of  new  growths,  whether  benign 
or   malignant.     A   tumor    in   the   pelvis,    of 
whatever   size,  is   always   a  menace   to   life 
and  health. 

3.  Cases  in  which  ovarian  neuralgia  and 
dysmenorrhoea  have   become   intolerable,  es- 
pecially if  occurring  in  women  who  depend 
upon   their  own   exertions  for   their   living. 
The   author   has   had   no   cases  which   have 
given  him  more  pleasing  and  satisfactory  re- 
sults than  these,  but  it  is  just  this  class  of 
cases  about  which  opinions  are  most  likely 
to   differ.     Withholding   an   operation   from 
a  woman  who  suffers  intensely  on  the  plea 
that  she  will  be  unable  to  bear  children  is 
unworthy  of   serious   consideration.     In  the 
majority  of  cases,  if  such  women  were  able 
to  bear  children,  the  children  would  be  feeble 
specimens  with  the  poorest  possible  chances 
of  receiving  the  care  and  attention  they  re- 
quired. 


THE  PREMATURE  MENOPAUSE.    243 

4.  Cases  in  which  Csesarean  section  has 
been  required  and  in  which  it  is  absolutely 
impossible  for  the  women  to  bear  children 
through  the  natural  channels.     This  will  not 
be  deemed  good  practice  by  all,  especially  by 
those  who  are  fond  of  doing  Csesarean  sec- 
tion.    The  wishes  of  the  woman  in  regard  to 
bearing  children  should  have  some  weight, 
but  the  author,  for   one,  can  not  conscien- 
tiously urge  a  woman  to  run  a  more  or  less 
decided  risk  of  losing  her  life  even  to  gratify 
the  natural  desire  for  offspring. 

5.  Cases  of  osteomalacia.     The  results  of 
the  operation  for  this  rare  disease  have  been 
very  gratifying. 

6.  Cases  in  which  the  uterus  is  the  seat 
of  inflammatory  trouble  or  new  growth  which 
is  the  cause  of  obstinate  pain,  haemorrhage, 
or  pressure  symptoms  which  can  be  relieved 
in  no  other  way.     It  is  not  infrequently  neces- 
sary to  remove  the  uterus  with  the  append- 
ages in  such  cases. 

Insanity,  epilepsy,  etc.,  have  been  consid- 
ered an  indication  by  some  writers,  but  the 


244  THE  MENOPAUSE. 

propriety  of  such  operations  is  doubtful  if 
the  insanity  is  the  result  of  a  brain  lesion. 
Battey  had  cured  but  one  such  case  out  of 
five  which  were  reported  by  him  in  1887.* 

THE  PHENOMENA  OF  THE  PREMATURE  MENO- 
PAUSE, INCLUDING  THOSE  WHICH  ACCOMPANY 
OPERATIONS  FOR  ITS  PRODUCTION. 

Menopause  may  be  established  Suddenly 
or  Gradually. — As  already  stated  (p.  204) 
the  premature  menopause  may  be  estab- 
lished abruptly,  without  any  of  the  symp- 
toms which  so  often  indicate  the  progress 
of  this  condition,  or  it  may  be  characterized 
by  some  or  all  of  those  symptoms.  When  it 
comes  as  an  accompaniment  of  serious  dis- 
ease— tuberculosis,  anaemia,  chronic  visceral 
diseases — the  absence  of  menstruation  alone 
indicates  that  it  has  occurred.  It  is  as  if 
the  vital  forces  were  all  occupied  in  oppos- 
ing the  march  of  a  deadly  enemy.  Explo- 
sions of  energy  and  force  which  are  so  com- 

*  Transactions  of  the  American  Gynaecological  Society, 
1887,  p.  253. 


THE  PEEMATURE  MENOPAUSE.          245 

mon  when  the  menopause  comes  at  the  usual 
time  are  wanting  because  there  is  no  surplus 
of  energy  and  force  to  explode. 

The  Phenomena  are  usually  the  same  as 
in  the  Natural  Process. — There  are  other 
cases  which  are  equally  without  symptoms 
marked,  like  those  which  have  just  been 
mentioned,  by  an  abrupt  cessation  of  the 
menstrual  flow  and  nothing  more.  Such 
may  be  the  history  of  those  who  have  sud- 
denly become  obese,  and  of  some  of  those 
from  whom  the  appendages  have  been  re- 
moved whether  the  degeneration  of  the  ova- 
ries be  complete  or  incomplete.  With  by  far 
the  greater  number  of  women,  however,  the 
history  is  that  of  women  who  are  going 
through  the  menopause  at  the  ordinary 
period  of  life.  But  if  the  appendages  have 
been  removed  the  bleeding,  if  it  recurs  at  all, 
usually  lasts  but  a  short  time,  other  symp- 
toms such  as  flashes  of  heat  and  various  nerv- 
ous and  vascular  phenomena  continuing  for 
varying  periods  of  time. 

The  removal  of  the  Uterus  may  be  re- 


246  THE  MENOPAUSE. 

quired  to  induce  the  Menopause. — There  are 
some  cases  of  bleeding  fibroid  of  the  uterus 
in  which  removal  of  the  ovaries  does  not 
cause  cessation  of  the  haemorrhage,  and  for 
such  the  removal  of  the  uterus  may  become 
an  ultimate  necessity. 

The  changes  which  occur  after  the  ova- 
ries have  been  removed  have  been  systemat- 
ically investigated  by  Glaevecke,*  also  the 
changes  in  the  organism  after  the  removal 
of  the  uterus.  After  the  ovaries  were  re- 
moved Glaevecke  found  that  menstruation 
ceased  in  88  per  cent  of  cases  either  at 
once  or  after  an  interval,  in  the  remaining 
12  per  cent  the  flow  became  scanty  and 
irregular.  Substitutional  haemorrhages  (ato- 
pomenorrhoea)  in  other  parts  of  the  body 
were  of  rare  occurrence.  In  50  per  cent  of 
the  cases  menstrual  molimina  continued  after 
the  cessation  of  the  flow.  Flushing,  vertigo, 
irregular  sweating,  leucorrlicea,  etc.,  were  of 
common  occurrence,  also  atrophy  of  the  gen- 

*  Archiv  ftir  Gynakologie,  xxxv,  1. 


THE  PREMATURE  MENOPAUSE.         247 

ital  organs.  Even  in  cases  in  which  the 
uterus  was  enlarged  by  chronic  endometritis 
or  fibroids  it  returned  to  its  original  size  or 
atrophied  in  most  of  the  cases.  The  general 
condition  improved  in  most  of  the  cases, 
and  in  42  per  cent  the  women  became 
obese.  Sexual  desire  was  usually  diminished 
and  in  some  cases  it  was  extinguished.  Psy- 
chical disturbances,  including  melancholia, 
were  sometimes  very  prominent.  It  was  be- 
lieved that  the  artificial  menopause  was  exactly 
similar  to  the  natural  one.  In  cases  in  which 
the  uterus  was  extirpated  the  menstrual  flow 
ceased,  but  in  some  cases  the  molimina  con- 
tinued a  few  months,  probably  as  the  result 
of  recurring  pelvic  congestion.  If  the  ova- 
ries were  not  removed  with  the  uterus  they 
atrophied,  though  it  was  believed  that  ovula- 
tion  continued  until  the  menopause  was  con- 
cluded. The  effect  upon  the  body  in  general 
of  removal  of  the  uterus  alone  was  not  so 
profound  as  from  the  removal  of  the  ovaries, 
and  sexual  feeling  was  rarely  changed.  In 
half  the  cases  there  was  no  psychical  dis- 


248  THE  MENOPAUSE. 

turbance,  but  in  a  third  of  them  there  was 
depression  tending  to  melancholia. 

To  these  opinions,  which  evidently  re- 
sulted from  careful  and  sufficiently  extensive 
investigations  and  with  which  the  author's 
experience  has  not  brought  him  entirely  into 
harmony,  may  be  added  the  conclusions  of 
Battey  after  fifteen  years'  careful  observation 
of  his  own  cases.* 

Of  the  54  cases  operated  upon  by  him, 
33  were  cured,  8  much  improved,  5  little 
improved,  8  not  improved.  In  50  cases  the 
menopause  resulted,  in  4  it  did  not.f 

In  almost  all  cases  he  believed  that  pa- 
tients must  pass  through  the  varying  experi- 
ence of  the  menopause  before  the  full  benefit 
of  the  operation  would  be  obtained,  and  this 
might  require  as  long  a  time  as  three  or  even 


*  See  Transactions  of  the  American  Gynaecological  So- 
ciety, 1887,  p.  253. 

f  It  is  to  be  remembered  that  the  express  object  which 
Battey  has  in  view  in  all  the  cases  upon  which  he  has  operated 
is  the  production  of  the  menopause.  It  is  this  which  he  be- 
lieves will  work  the  cure  in  cases  which  are  curable  by  such 
an  operation. 


THE  PREMATURE  MENOPAUSE.          249 

five  years.  Much  would  also  depend  upon  a 
judicious  selection  of  cases ;  of  course,  some 
patients  would  be  incurable  by  any  opera- 
tion, and  this  would  include  some  who  had 
long  been  subject  to  vicious  habits,  to  the  use 
of  alcohol,  chloral,  opium,  etc. 

He  observed  that  in  some  cases  there  was 
an  intractable  pelvic  neuralgia  following  the 
operation,  which  he  thought  was  caused  by 
pressure  of  the  unabsorbed  ligature  upon  the 
stump.  This  phenomenon  has  been  observed 
by  others,  the  author  included,  but  the  au- 
thor thinks  that  this  condition  is  by  no  means 
universally  attributable  to  such  a  cause. 
Many  such  cases  were  formerly  treated  by 
him  with  electricity,  with  relief  to  the  pain, 
at  least  for  the  time.  The  discouraging  part 
of  such  treatment  is  the  length  of  time  dur- 
ing which  it  must  be  employed.  Both  pa- 
tient and  physician  become  weaiy  of  its  use. 

Battey  did  not  believe  that  the  removal 
of  the  Fallopian  tubes  had  any  influence 
upon  the  final  result,  either  with  reference  to 
the  establishment  of  the  menopause  or  in  the 


250  THE  MENOPAUSE. 

final  cure  of  the  disease,  except  in  so  far  as 
the  tubes  themselves  were  the  seat  of  disease. 
In  this  respect  he  took  issue  with  Tait,  who 
regarded  the  tubes  as  the  essential  organs  of 
menstruation  aside  and  apart  from  their  func- 
tion as  oviducts. 

Important  observations  upon  this  subject 
of  the  changes  which  follow  the  removal  of 
the  ovaries  have  also  been  made  by  Hegar.* 
He  called  attention  to  the  fact  that  the  gen- 
eral structure  of  the  body,  pelvis,  breasts,  ex- 
ternal genitals,  sexual  desire,  and  the  mode 
of  feeling  are  independent  of  the  ovaries  or 
only  relatively  dependent  on  them. 

In  young  female  animals  spaying  is  fol- 
lowed by  a  more  quiet  temperament  than 
ordinarily  exists,  a  tendency  to  the  deposit  of 
fat,  and  cessation  in  the  growth  of  all  parts 
of  the  genital  apparatus.  He  also  made  the 
very  reasonable  suggestion  that  one  must  not 
be  disappointed  if  the  menopause  did  not  re- 
sult at  once  in  women  with  whom  the  habit 

*  Operative  Gynaecology.     Cyclopaedia  of  Obstetrics  and 
Gynaecology,  vol.  vi,  p.  291. 


THE  PREMATURE  MENOPAUSE.    251 

of  menstruation  had  existed  many  years  with 
the  recurrent  molimina  and  turgescence  of 
organs  and  tissues.  He  also  admitted  the 
possibility  of  the  blending  of  the  sexual 
types,  with  growth  of  hair  upon  the  face, 
deeper  voice,  change  of  ideas,  and  of  the  men- 
tal and  emotional  life.  This,  just  as  in  cer- 
tain animals  there  were  analogous  changes, 
the  peahen  assuming  the  feathers  and  ap- 
pearance of  the  male  after  ovulation  had 
ceased,  and  the  antlers  of  the  doe  becoming 
better  developed.  But  Hegar  avowed  that 
he  had  never  seen  the  assumption  of  this 
masculine  type  in  those  whose  ovaries  had 
been  removed.  With  this  experience  of  He- 
gar's  the  author  concurs,  and  it  would  seem 
to  him  that  if  the  condition  in  question  were 
ever  to  occur  it  would  be  in  the  case  of 
women  whose  ovaries  were  removed  at  a 
time  remote  from  that  in  which  the  meno- 
pause would  under  ordinary  conditions  take" 
place. 

It  is  an  agreeable  thought  that  with  many 
women   beauty    becomes    more    pronounced 


252  THE  MENOPAUSE. 

with  advancing  age ;  coarseness  of  features  is 
an  event  far  from  common  in  its  occurrence 
with  those  whom  we  have  known  and  loved, 
and  we  readily  admit  that  the  type  of  beauty 
is  not  that  of  youth. 

The  Menopause  is  Premature  when  occur- 
ring Prior  to  the  Fortieth  Year. — The  au- 
thor's experience  with  those  who  have  reached 
the  menopause  prematurely  has  not  been  in- 
considerable, either  in  public  or  in  private  prac- 
tice, and  it  extends  over  a  period  of  more 
than  sixteen  years.  In  the  class  of  cases 
which  has  come  under  his  observation  in  the 
city  of  New  York  and  its  surroundings  he 
has  been  accustomed  to  regard  the  meno- 
pause as  premature  if  it  occurred  prior  to  the 
fortieth  year. 

Of  those  who  have  reached  it  as  the  re- 
sult of  wasting  disease  the  rule  has  been,  as 
already  stated,  that  the  only  prominent  symp- 
tom was  the  cessation  of  menstruation. 

Tlie  Obese  suffer  considerably,  as  a  Rule. 
— The  obese  who  have  suffered  with  dys- 
menorrhcea  and  sterility,  and  the  obese  who 


THE  PREMATUKE  MENOPAUSE.          253 

have  become  so  after  bearing  a  large  family 
of  children,  almost  invariably  suffer  with  the 
vasomotor  troubles,  to  which  attention  has  so 
frequently  been  called.  Several  cases  have 
been  observed  in  which  an  early  menopause 
was  reached,  the  patients  being  unconscious 
that  it  had  taken  place ;  the  fact  was  casually 
determined  while  investigating  the  condition 
of  the  patient  for  other  troubles. 

Removal  of  the  Appendages  of  One  Side 
does  not  induce  the  Menopause. — A  great 
number  of  cases  has  been  seen  in  which 
the  menopause  has  followed  removal  of  the 
uterine  appendages,  and  the  observation  of 
these  cases  has  been  continued  during  months 
and  years.  They  have  included  not  only  the 
author's  cases,  but  those  of  numerous  other 
surgeons.  The  following  phenomena  have 
been  observed :  If  the  appendages  from  only 
one  side  have  been  removed  the  menopause 
has  never  been  observed  to  occur,  and  symp- 
toms which  have  been  attributable  to  the 
functional  activity  of  the  ovaries  (e.  g.,  uter- 
ine haemorrhage)  have  not  been  alleviated  by 


254  THE  MENOPAUSE. 

the  removal  of  one  ovary,  even  though  that 
might  be  seriously  diseased. 

The  Menopause  may  be  deferred  even 
though  both  Ovaries  be  Removed. — If  the 
appendages  of  both  sides  have  been  thor- 
oughly removed  the  menopause  has  invari- 
ably occurred,  excepting  in  cases  of  uterine 
myoma  adherent  to  surrounding  structures 
in  which  activity  and  vascularity  were  con- 
tinued through  this  adventitious  relation.* 

Concerning  Supernumerary  Ovaries. — 
Much  has  been  said  at  various  times  about 
the  existence  of  supernumerary  ovaries.  The 
author  has  been  skeptical  as  to  their  exist- 
ence, or  rather  as  to  their  functional  power. 

*  An  exception  has  recently  occurred  in  the  author's  prac- 
tice. A  woman  twenty-six  years  of  age  was  operated  upon 
by  the  author  in  June,  1890,  for  ruptured  tubal  pregnancy. 
Both  ovaries  and  tubes  were  removed  as  thoroughly  as  pos- 
sible. The  patient  has  menstruated  ever  since  with  perfect 
regularity  until  four  months  ago,  when  menstruation  failed 
to  appear  and  has  remained  in  abeyance.  She  also  has  most 
marked  vasomotor  phenomena,  and  is  apparently  experi- 
encing the  menopause.  She  returned  to  the  author  on  ac- 
count of  an  enormous  ventral  hernia,  which  was  operated 
upon,  and  nothing  found  in  the  pelvis  to  indicate  that  the 
previous  operation  had  been  defective. 


THE  PREMATURE  MENOPAUSE.          255 

At  the  last  meeting  (1896)  of  the  American 
Gynaecological  Society  cases  were  narrated  in 
which  total  extirpation  of  the  appendages  was 
supposed  to  have  been  performed,  and  the 
operations  were  followed  by  pregnancy  and 
delivery  at  term.  This  is  rather  staggering 
to  one's  cherished  convictions.  The  dilemma 
which  is  offered  is  that  a  supernumerary 
ovary  existed,  with,  of  course,  some  commu- 
nication with  the  stump  of  the  tube,  or  that 
the  operations  in  question  were  defective  and 
incomplete.  In  any  event,  it  is  difficult  to 
see  how  an  opening  could  be  made  in  the 
stump  of  the  tube,  and  at  the  proper  place, 
for  the  ingress  of  an  escaped  ovum. 

Arthur  Johnstone  offers  a  solution  to  the 
riddle  in  the  statement  that  the  Fallopian 
tubes  have  accessory  ostia,  and  that  one  or 
more  of  them  may  reopen  in  the  stump,  espe- 
cially if  the  tube  were  ligated  with  catgut. 

Of  the  two  cases  reported  by  Gordon  at 
the  meeting  in  question  the  first  can  be 
readily  dismissed,  the  evidence  being  entire- 
ly inconclusive  that  both  ovaries  had  been 


256  THE  MENOPAUSE. 

removed.  In  the  second,  in  which  the  ap- 
pendages were  removed  by  Gordon,  the  ex- 
planation of  the  pregnancy  is  not  easy. 

In  the  great  majority  of  cases  the  month- 
ly bleeding  has  ceased  at  once ;  in  some  cases 
it  has  continued  a  few  months ;  in  none,  with 
the  exception  of  myomatous  cases,  has  it  per- 
sisted as  long  as  a  year  after  the  opera- 
tion.* 

Atrophy  of  the  uterus  is  considerable  in 
most  cases  within  a  year  from  the  operation. 
This  is  especially  noticeable  in  middle-aged 
women.  In  young  women,  especially  in  the 
married  and  in  prostitutes,  atrophic  changes 
are  much  less  marked. 

The  author  has  never  seen  but  one  case 
in  which  any  domestic  unhappiness  had  been 
caused  by  the  so-called  sterilizing  operation ; 
this  was  in  a  young  and  wretchedly  poor 
Russian  Jewess  who  said,  with  tears  in  her 
eyes,  some  months  after  her  operation,  that 
her  husband  told  her  she  was  "  no  good  "  any 

*  See  also  in  this  connection  the  statements  of  Glaevecke, 
p.  246;  also  Diihrssen  Archiv  fur  Gynakologie,  1889. 


THE  PREMATURE  MENOPAUSE.         257 

longer,  being  unable  to  bear  children,  men- 
struate, or  respond  to  his  sexual  ardor.  But 
the  author  has  often  listened  to  a  similar 
story  from  women  who  have  not  been  de- 
prived of  their  ovaries. 

Concerning  Sexual  Desire  in  its  Rela- 
tions with  the  Menopause. — Much  has  been 
said  against  this  operation  which  is  under 
consideration  because  of  its  supposed  effect 
in  abolishing  the  sexual  appetite.  It  is  pos- 
sible that  the  operation  has  very  little  to  do 
with  the  sexual  appetite.  A  woman  who  is 
without  sexual  ardor  prior  to  an  operation 
will  not  be  likely  to  acquire  it  afterward ; 
the  operation  does  not  create  the  desire. 
Those  who  are  of  ardent  disposition  will 
not  be  likely  to  lose  it  by  the  removal  of 
the  ovaries,  at  least  not  for  months  and 
years.  In  other  words,  young  women  will 
not  be  much  affected  as  to  their  sexual  de- 
sire, middle-aged  and  old  women  may  lose 
it,  and  it  is  quite  proper  at  such  periods  of 
life  that  they  should. 

The  author   has   repeatedly  interrogated 

18 


258  THE  MENOPAUSE. 

prostitutes  who  had  been  operated  upon,  and 
has  never  seen  one  who  admitted  that  the 
operation  had  affected  her  in  this  respect. 
He  has  seen  women  with  whom  sexual  in- 
tercourse was  the  cause  of  intense  pain  and 
dread  who  were  entirely  relieved  by  the  op- 
eration, and  were  enabled  to  endure  sexual 
intercourse  without  pain  or  dread.  He  has, 
on  the  other  hand,  seen  middle-aged  women 
who  said  their  husbands  had  ceased  to  have 
intercourse  with  them  long  before  they  were 
operated  upon,  and  had  made  no  attempt  to 
renew  the  sexual  relation  after  the  operation. 
He  would  therefore  submit  that  the  day  has 
passed  for  any  rational  man  or  woman  to 
urge  the  sterilizing  or  unsexing  effect  of  the 
removal  of  the  ovaries  as  a  valid  excuse  in 
cases  in  which  the  operation  is  indicated. 
This  is  said  with  full  consciousness  of  the 
power  of  human  passion,  and  of  the  fact 
that  it  is  a  perfectly  natural  thing  for  wom- 
en to  bear  children ;  but  it  is  also  urged  that 
the  sole  function  of  a  woman  is  neither  the 
bearing  of  children,  especially  if  she  is  unfit 


THE  PREMATURE  MENOPAUSE.    259 

to  bear  healthy  children,  nor  the  gratification 
of  the  sexual  appetite,  and  it  is  a  sad  com- 
mentary on  human  nature  and  the  quality 
of  the  love  which  men  have  for  their  wives 
when  the  present  or  prospective  inability  of 
the  latter  to  gratify  the  sexual  appetite  of 
the  former  is  held  up  as  an  excuse  for  with- 
holding from  them  the  advantages  of  a  be- 
neficent operation. 

Pain  and  Neuralgia  not  always  Cured 
by  removal  of  Appendages. — In  a  number  of 
cases  a  continuance  of  the  pain  and  neuralgia, 
which  formed  an  indication  for  operation, 
have  been  observed  for  a  more  or  less  pro- 
longed period  after  its  performance.* 

This  pain  has  always  yielded  to  the  in- 
fluence of  electricity  (see  page  249),  though 
months  of  treatment  might  be  required  be- 
fore it  was  permanently  relieved.  In  most 
of  the  author's  cases  the  vasomotor  disturb- 
ances so  common  with  the  menopause  at  the 
usual  period  of  life  were  present,  but  in  some 

*  See  also  Battey's  remarks  upon  this  subject,  p.  248. 


260  THE  MENOPAUSE. 

of  them,  especially  in  very  young  women, 
nothing  of  the  kind  was  complained  of. 

Only  one  case  has  been  observed  in  which 
melancholia  developed,  and  this  was  relieved 
after  treatment  which  was  continued  about  a 
year. 

In  the  great  majority  of  the  cases  in 
which  the  appendages  have  been  removed  by 
the  author  for  salpingitis  and  ovaritis  the  re- 
lief has  been  prompt,  complete,  and  permanent. 

The  Effect  of  removing  the  Ovaries  prior 
to  Puberty  has  not  been  thoroughly  investi- 
gated.— The  effect  of  removing  the  ovaries 
prior  to  puberty  can  not  be  stated  with 
the  definiteness  which  could  be  desired,  for 
there  is  little  testimony  upon  this  subject 
which  is  available.  The  indications  for  such 
operations  are  fortunately  very  few  and 
limited.  If  we  were  to  reason  from  the  effect 
of  the  corresponding  operations  upon  animals 
we  might  expect  such  changes  in  the  struc- 
ture and  bearing  of  the  individuals  as  would 

O 

render  them  disagreeably  conspicuous  among 
their  fellow-beings. 


THE  PREMATURE  MENOPAUSE.          261 

The  Changes  which  occur  in  Eunuchs  are 
Suggestive. — The  changes  which  take  place  in 
eunuchs  are  sufficiently  well  known,  and  there 
is  no  reason  to  suppose  there  would  not  be 
analogous  changes  in  females  if  the  ovaries 
were  removed  before  physical  development 
had  been  completed.  So  pelvic  congestion 
having  never  been  established,  it  would  not 
be  within  the  range  of  the  probable  that  the 
changes  which  accompany  its  arrest,  whether 
abruptly  or  gradually,  would  be  observed. 
Nondevelopinent  of  the  genital  structures, 
the  breasts,  and  the  external  genitals  would 
be  expected,  because  there  would  be  no  func- 
tional use  for  such  structures.* 


*  A  case  which  bears  somewhat  upon  the  foregoing  oc- 
curred in  the  author's  practice,  and  is  as  follows :  The  patient 
was  a  small,  illy-developed  girl  of  fifteen  when  first  seen  by 
the  author  in  1892.  The  vagina  was  absent,  but  menstrua- 
tion had  been  established,  causing  the  development  of  an 
abdominal  tumor  extending  nearly  to  the  umbilicus.  This 
tumor  was  evacuated  by  an  incision  through  the  rectum. 
Subsequently  an  opening  was  torn  through  the  tissue  be- 
tween the  rectum  and  the  bladder  and  drainage  effected. 
After  a  time  the  drainage  tube  was  removed,  and  this  was 
followed  by  closure  of  the  artificial  canal  and  a  reaccumula- 
tion  of  menstrual  fluid.  An  abdominal  section  was  then 


262  THE  MENOPAUSE. 


APPARENT  MENOPAUSE  OCCURRING 
PREMATURELY. 

Cases  in  which  Menstruation  is  Sus- 
pended, but  may  Return. — In  not  a  few  cases 
in  which  the  menstrual  flow  is  suspended  this 
suspension  is  only  temporary.  Attention  has 
already  been  called  to  cases  in  which  this  was 
the  permanent  result  of  sickness  or  disease  of 
varying  character,  in  an  earlier  portion  of  this 
chapter. 

In  a  certain  percentage  of  cases  in  which 
no  menstruation  appears  for  a  number  of 
months  Nature  will  provide  for  the  return  of 

performed,  the  ovaries  removed,  and  in  the  course  of  the 
following  two  or  three  months,  by  a  process  of  dilating  and 
tearing,  a  substitute  for  a  vagina  was  constructed  about 
two  inches  long.  After  an  interval  of  three  years  the  fol- 
lowing information  was  obtained :  The  patient  has  had  ex- 
aggerated vasomotor  phenomena,  flashes  of  heat  and  cold, 
and  sensations  of  perspiration  upon  her  limbs.  She  has  not 
gained  in  weight,  her  breasts  are  undeveloped,  her  voice  has 
not  changed,  there  is  no  hair  on  her  face,  and  only  a  slight 
growth  upon  the  pubes.  She  has  pleasure  and  satisfaction 
such  as  is  usual  and  proper  in  the  society  of  young  men. 
The  vaginal  passage  is  one  inch  and  a  half  long  and  tapers  to 
a  point.  General  health  excellent. 


THE  PREMATURE  MENOPAUSE.         263 

the  flow  at  the  proper  time,  but  in  other 
cases  some  assistance  must  be  rendered.  It 
would  be  easy  to  anticipate  a  further  elucida- 
tion of  this  subject  by  recalling  the  condition 
in  which  the  function  was  only  in  abeyance 
for  the  time,  and  for  the  benefit  of  the  stu- 
dent it  may  be  said  that  these  cases  must  be 
carefully  distinguished  from  those  in  which 
the  cessation  is  permanent  though  premature. 
No  unerring  rules  can  be  given  for  determin- 
ing the  one  from  the  other ;  each  case  is  sui 
generis,  and  must  be  studied  on  its  own 
merits.  Therefore  a  strict  classification  of 
such  cases  would  be  out  of  the  question,  and 
one  must  be  content  to  mention  conditions  in 
which  groups  of  such  cases  may  appear. 

Menstruation  may  be  Suspended  a  few 
Months  and  then  return. — Allusion  has  been 
made  (page  137)  to  the  influence  which  a 
heavy  atmosphere  (e.  g.,  during  a  sea  voyage) 
may  have  in  suspending  menstruation,  many 
examples  of  which  are  to  be  seen  in  New 
York  among  our  young  immigrant  women. 
It  has  been  particularly  noticeable  among  the 


264:  THE  MENOPAUSE. 

Irish  and  Swedes,  usually  among  the  unmar- 
ried, and  especially  among  those  who  are 
anaemic  and  deficient  in  vitality.  This  sus- 
pension may  last  several  months,  perhaps  as 
long  as  a  year,  and  with  the  recurrence  of 
vigorous  health  is  almost  invariably  followed 
by  the  return  of  the  flow.  In  anaemic  women 
in  general  the  temporary  cessation  of  the 
menses  is  a  desirable  incident.  It  is  Nature's 
call  for  the  accumulation  rather  than  the  dis- 
tribution of  blood  and  blood-making  ele- 
ments. If  the  call  is  heeded  the  result  \vill 
usually  be  returning  health  and  re-established 
menstrual  function.  In  these  and  all  other 
cases  of  suspended  menstruation  one  must 
never  lose  sight  of  the  possibility  of  the  pres- 
ence of  the  pregnant  state,  and  must  not  be 
beguiled  by  external  appearances  or  the  state- 
ments of  patients. 

In  any  case  of  suspended  menstruation  in 
which  the  condition  causing  it  does  not  lead 
to  a  fatal  result,  whether  the  cause  be  any  of 
those  which  have  been  mentioned,  acute  or 
chronic  disease,  or  traumatism,  we  must  ever 


THE  PREMATURE  MENOPAUSE.          265 

consider  the  possibility  of  restoration  of  the 
disturbed  function. 

Attempts  at  Restoration  may  be  Futile. — 
In  some  cases  all  efforts  in  this  direction  will 
prove  futile,  in  others  they  will  be  crowned 
with  success,  and  the  satisfaction  in  such 
cases  is  usually  considerable  to  all  who  have 
been  concerned  with  them.  It  is  well  enough 
to  state  that  some  cases  are  quite  hopeless, 
and  offer  no  prospect  of  any  advantage  from 
treatment  of  any  character.  Such  are  cases 
of  great  obesity,  exhaustion  from  excessive 
childbearing  or  hard  work,  or  excesses  in  al- 
cohol and  venery,  and  usually  superinvolu- 
tion ;  also  the  occasional  cases  in  which  there 
is  defective  development  of  the  genital  or- 
gans, and  in  which  menstruation  has  never 
reached  the  condition  of  a  mature  function. 

ADDENDA. 

MONTGOMERY.  The  Premature  Menopause.  Med- 
ical News,  1894,  Ixv,  p.  461. 

KLEINWACHTER.  Ein  Beitrag  zur  Battey-Hegar- 
'schen  Operation.  Archiv  fur  Gynakologie,  xvi. 

ODEBRECHT.  Ein  Beitrag  zur  Castration  des 
Weibes.  Berliner  Klinische  Wochenschrift,  1881. 


266  THE  MENOPAUSE. 

HEGAR.  Die  Castration  der  Frauen.  Leipzig, 
1878. 

ORMIERE.  Sur  la  menstruation  apres  1'Ovariotomie 
et  1'Hysterectomie.  These  de  Paris,  1880. 

TISSIER.  De  la  Castration  de  la  Femme.  These 
de  Paris,  1885. 

TAUFFER.  Beitriige  zur  Lehre  der  Castration  der 
Frauen.  Zeitschrift  fiir  Geburtshiilfe  und  Gyniikolo- 
gie,  ix,  1883. 

PROCHOWNIK.  Beitriige  zur  Castrationsfrage. 
Archiv  fiir  Gyniikologie,  xxix. 

PEAN.  De  1'Ablation  des  Tumeurs  du  Ventre  con- 
sideree  dans  ses  Eapports  avec  Menstruation,  etc. 
Gazette  Medicale  de  Paris,  1880. 

KEHRER.  Versuche  uber  Castration  und  Erzen- 
gung  von  Hydrosalpinx.  Beitriige  zur  Klinischen 
und  experimentellen  Geburtskunde  und  Gyniikologie, 
Band,  ii,  Heft  3,  Giessen,  1887. 

BRUXTZEL.  Vier  Castrationen.  Archiv  fiir 
Gyniikologie,  xvi. 


CHAPTER   VI. 

RETARDED    MENOPAUSE. 

THIS  term  does  not  refer  to  those  cases  in 
which  bleeding  at  irregular  intervals  takes 
place  years  after  the  customary  flow  has 
ceased.  Such  cases  are  not  instances  of  re- 
tarded menopause,  but  of  disease  of  the  uter- 
ine structure,  and  may  occur  at  advanced 
periods  of  life,  perhaps  many  years  after  the 
regular  menopause  has  occurred. 

Cases  of  Menstruation  prolonged  beyond 
the  Fiftieth  Year. — There  are  exceptional 
cases  in  which  menstruation  seems  to  be  pro- 
longed beyond  a  reasonable  limit — that  is, 
beyond  the  fiftieth  year — for  it  is  clear,  as 
has  been  already  stated,  that  in  temperate 
climates  we  may  consider  the  decade  between 
the  fortieth  and  fiftieth  years  as  the  period  in 
which  the  menopause  occurs  with  the  great 

267 


208  THE  MENOPAUSE. 

majority  of  women.  In  some  families  it 
seems  to  be  usual  for  the  menopause  to  be 
deferred  beyond  the  fiftieth  year  without  ap- 
preciable disturbance  to  the  individual.* 

*  An  instance  of  this  kind  has  already  been  noted  in 
Chapter  III,  p.  101. 

Petrequin,  in  an  analysis  of  60  cases  of  women  who  had 
passed  the  menopause,  found  7  in  whom  it  came  between  the 
fiftieth  and  fifty-fifth  years. 

Scanzoni  believed  that  no  women  menstruate  naturally 
beyond  the  fifty-third  year. 

Mayer  (Expose  Statistique  de  la  Menstruation  dans  1'Alle- 
magne  Septentrionale  et  Centrale)  reports  the  delayed  meno- 
pause in  one  women  at  60,  in  3  at  59,  and  in  6  at  58.  In  his 
analysis  of  6,000  cases,  most  of  the  women  being  residents  of 
Berlin,  there  were  115  who  reached  the  menopause  between 
the  ages  of  50  and  64. 

J.  Kennedy  (quoted  by  Borner,  op.  cit.)  knew  of  a  woman 
who  had  a  child  in  her  sixty-second  year,  She  began  to 
menstruate  at  13,  bore  her  first  child  at  20,  and  between  that 
age  and  62  had  20  additional  children. 

Rodsewitsch  (from  Borner)  collected  from  Russian  litera- 
ture, between  the  years  1872  and  1881,  11  cases  in  which 
children  were  born  between  the  ages  of  50  and  55. 

Sutherland  reports  a  case  (British  Medical  Journal,  ii, 
1879,  p.  774)  in  which  a  condition  which  he  supposed  to  be 
a  renewal  of  menstruation,  after  8  years'  cessation,  began  at 
the  age  of  59. 

Orfila  is  said  to  have  reported  the  case  of  a  woman  who 
had  her  first  child  at  47  and  her  seventh  and  last  at  60,  men- 
struation continuing  until  she  was  99. 

Mayer  has  correctly  observed  that  uterine  tumors  may 
grow  after  the  menopause  has  apparently  occurred  and  cause 


RETARDED  MENOPAUSE.  269 

The  author  has  recently  seen  and  oper- 
ated upon  a  woman  of  sixty-nine  who  sus- 
pected a  renewal  of  menstruation  on  account 
of  profuse  haemorrhages.  The  case  was  one 
of  carcinoma  of  the  uterus.  He  has  seen 
other  similar  cases. 

All  cases  of  haemorrhage  from  the  uterus 
which  occur  late  in  life — that  is,  after  the 
fiftieth  year — should  therefore  excite  suspi- 
cion of  the  existence  of  malignant  disease, 
and  should  not  be  looked  upon  as  a  necessary 
accompaniment  of  the  menopause  or  as  a  re- 
newal of  the  menstrual  function.  If  this 
fact  is  borne  in  mind  many  cases  may  be  re- 
lieved which  it  has  heretofore  been  the  fash- 
ion to  allow  to  remain  untreated. 


uterine  bleedings  which  may  be  mistaken  for  a  renewal  of  men- 
struation. Such  tumors  may  become  fibro-cystic  or  sarcoma- 
tous  and  cause  irregular  bleedings,  and  this  fact  has  been 
observed  by  Tait,  Schorler,  Borner,  Gusserow,  and  others. 


CHAPTER  VII. 

TREATMENT. 

Carefulness  and  Watchfulness  requisite. 
—What  treatment  is  indicated  for  women 
who  are  passing  through  the  menopause  ? 
Certainly  the  old  method  was  radically 
wrong,  which  consisted  in  ignorant  inactivity. 
To  this  extent  it  may  be  admitted  that  the 
period  of  the  change  of  life  is  a  critical  time 
—namely,  that  it  is  a  time  to  be  watchful 
and  active.  That  eternal  vigilance  which  is 
the  price  of  liberty  may  also  serve  a  very 
good  purpose  in  making  one  always  prepared 
for  any  mishap  which  may  occur  during  the 
menopause. 

Glasses  of  Women  with  whom  the  Meno- 
pause should  be  Uneventful. — The  author  be- 
lieves, as  he  has  already  asserted,  that  the 
majority  of  women  will  not  require  to  have 

270 


TREATMENT.  271 

anything  done  by  a  physician  during  this  pe- 
riod, reaffirming  a  proposition  already  enun- 
ciated, that  a  process  through  which  every 
mature  woman  has  to  pass  can  not  be  ex- 
pected to  have  abnormalities  in  all  or  even  in 
the  majority  of  cases.  Among  savage  and 
barbarous  women,  among  women  who  live 
out  of  doors  and  are  inured  to  manual  labor 
or  exercise,  the  occasions  will  be  rare  indeed 
in  which  any  aid  from  a  physician  will  be  re- 
quired in  order  to  meet  the  exigencies  of  the 
menopause. 

Classes  of  Women  wlio  suffer.  Tlie  treat- 
ment is  tliat  of  Symptoms. — Among  the  nerv- 
ous, highly  organized,  sensitive  women  who 
spend  the  most  of  their  lives  in  the  house, 
among  those  who  are  harassed  with  cares  do- 
mestic and  social,  the  fashionable  and  dissi- 
pated, among  those  who  have  suffered  with 
pelvic  troubles  more  or  less  of  their  lives, 
among  many  who  have  suffered  from  poverty 
or  disappointment,  the  menopause  will  call 
for  more  or  less  constant  attention,  and  it 
will  be  well  to  remember  that  we  have  no 


272  THE  MENOPAUSE. 

definite  disease,  as  a  rule,  to  treat,  but  a 
series  of  symptoms. 

Vasomotor  PJienomena  tlie  most  Fre- 
quent.— Let  us  first  consider  the  treatment  of 
those  who  are  affected  with  nervous  and  vas- 
cular troubles,  for  this  includes  by  far  the 
greater  number  of  sufferers  at  the  meno- 
pause.* 

The  vasomotor  troubles,  blushes,  flashes 
of  heat  with  possible  subsequent  profuse 
perspiration  or  discharge  of  urine,  which 
sometimes  persist  until  advanced  life,  form 
the  commonest  of  all  symptoms  and  fre- 
quently appear  with  women  who  are  in  other 
respects  in  the  most  perfect  health.f 

Many  of  these  women  would  scorn  the 
idea  of  medical  treatment  or  even  advice  for 
such  a  condition,  but  there  are  many  others 


*  See  remarks  on  climacteric  insanity,  Chapter  IV;  see 
also  Geber,  Anomalien  der  Schweissdriisen  und  ihrer  Func- 
tion, in  Ziemssen  Handbuch  der  speciellen  Pathologic  und 
Therapie,  xiv,  Heft  2. 

t  C.  Liegeois  recommends  the  use  of  atropia  sulphate 
for  the  sweating  of  the  menopause,  which  is  sometimes  very 
annoying.  Revue  medicale  de  1'Est,  Nancy,  xi,  p.  460. 


TEEATMENT.  273 

who  are  so  annoyed  by  it  that  they  seek  re- 
lief. Such  women  should  always  pay  close 
attention  to  the  condition  of  the  gastro-intes- 
tinal  canal,  their  diet  should  be  simple  and 
wholesome ;  alcohol,  spices,  highly  seasoned 
food  should  be  abstained  from ;  the  bowels 
should  be  kept  freely  open,  and,  as  such  peo- 
ple are  in  very  many  instances  constipated,  a 
gentle  purge,  especially  with  salines,  should 
occasionally — that  is,  according  to  the  urgency 
of  the  condition — be  given. 

Salines  and  Nervines. — The  so-called  nerv- 
ines, valerian,  asafoetida,  scutellarium,  hyo- 
scyamus,  etc.,  will  all  be  found  serviceable  occa- 
sionally. Another  most  important  matter  con- 
sists in  encouraging  free  elimination  through 
the  skin  by  exercise,  friction,  and  frequent 
bathing  in  water  at  a  temperature  of  60°  to  70° 
F.  Salt-water  baths  will  be  found  a  particu- 
larly grateful  and  efficient  mode  of  treatment. 

Abstraction  of  Blood  for  Congestions  of 
the  Pelvic  Organs. — The  author  has  alluded 
to  the  congestions  of  the  genital  organs, 
which  are  sometimes  particularly  distress- 

19 


274  THE  MENOPAUSE. 

ing  in  causing  sexual  excitement.  He  has 
known  cases  in  which  this  was  a  source  of 
great  mortification  to  very  worthy  women. 
Such  congestions  are  a  valid  cause  for  pro- 
fessional assistance.  Relief  may  often  be 
obtained  by  the  abstraction  of  blood  from 
the  os  uteri  either  with  leeches  or  by  means 
of  punctures  with  a  tenaculum  or  scalpel, 
an  ounce  or  more  of  blood  being  removed. 
Vaginal  douches  with  water  at  a  tempera- 
ture not  exceeding  70°  or  75°  F.  would  also 
be  found  efficient,  and  the  intelligence  of 
such  patients  should  be  appealed  to  by  a 
candid  statement  of  the  condition  and  the 
means  required  for  its  relief.* 

Profuse  Haemorrhages  during  the  Meno- 
pause are  an  Evidence  of  Disease. — The  con- 
gestions of  the  genital  organs  which  cause 
free  haemorrhage  at  the  time  when  the 
menopause  is  supposed  to  be  present  should 
always  receive  investigation  and  explana- 

*  See  in  reference  to  this  feature  of  the  subject  H.  Ricord, 
Etudes  sur  les  Troubles  de  la  Sensibilite"  G6n6sique  a  1'Epoque 
de  la  Menopause,  Paris,  1879. 


TEEATMENT.  275 

tion.  It  is  insisted,  as  has  been  insisted 
repeatedly,  that  they  are  not  physiological, 
they  are  not  normal,  but  are  the  evidence 
of  disease.  Excluded  are  those  congestions 
and  haemorrhages  which  occur  years  after 
the  menopause  has  occurred,  which  have 
heretofore  been  explained  by  many  physi- 
cians as  a  renewal  of  menstruation,  a  second 
experience  of  the  menopause,  which  ex- 
planation is  absurd,  for  they  always  indi- 
cate disease,  and,  with  those  who  are  ad- 
vanced in  life,  usually  or  often  malignant 
disease. 

Vasomotor  Paralysis  may  be  a  Factor  in 
ike  HcemorrJiages  of  the  Menopause. — It  is 
probable  that  there  is  in  these  menopause- 
uterine  haemorrhages  the  same  element  of 
vasomotor  paralysis  which  occurs  in  other 
parts  of  the  body,  and  that  the  uterine 
capillaries  and  their  supporting  connective 
tissue  have  less  resisting  power  on  account 
of  atrophy  and  fatty  degeneration  processes 
which  are  going  on  than  they  have  had  in 
previous  years.  Hence  whenever  the  vaso- 


276  THE  MENOPAUSE. 

motor  paralysis  occurs  the  resulting  haemor- 
rhage is  much  more  likely  to  be  profuse 
than  when  the  tissues  have  the  vitality  of 
earlier  years.  The  haemorrhage  is  more  pro- 
fuse and  more  persistent  if  there  is  also  a 
diseased  endometrium  or  a  neoplasm  in  the 
parenchyma  of  the  uterus. 

Carettage.  -  -  The  treatment  should  be 
mainly  surgical ;  the  uterus  should  be  di- 
lated, the  endometrium  examined,  a  wire 
curette  being  carefully  passed  over  its  en- 
tire surface,  first  for  diagnosis  and  then 
with  sufficient  force  to  break  down  and  re- 
move all  diseased  tissue  if  any  there  be, 
and  this  operation  should  be  repeated  if 
the  occasion  warrants.  This  is  a  more  log- 
ical and  rational  procedure  than  tampon- 
ing the  vagina,  or  even  the  uterus,  previ- 
ous exploration  of  the  uterine  cavity  not 
having  been  made. 

If  an  uterine  tumor  causes  severe  bleed- 
ing one  may  practice  galvano-cauterization 
of  the  endometrium  with  the  positive  pole, 
and  if  this  fails  to  be  effective  and  there  is 


TREATMENT.  277 

prospect  of  a   troublesome   future,  hysterec- 
tomy should  be  performed. 

Radical  Measures  indicated  for  Cancer.— 
Should  cancer  of  the  uterus  develop  at  this 
time — and  this  is  possible,  for  it  may  de- 
velop at  any  period  of  life — hysterectomy, 
usually  per  vaginam,  is  indicated  at  the 
earliest  possible  moment.  Baker,  Byrne,  and 
others  have  had  excellent  results  from  the 
high  amputation  of  the  cervix  for  cancer, 
Baker  using  the  scissors  and  cautery  in  his 
operations  (several  of  which  were  followed 
by  cures,  the  patients  being  alive  and  well 
from  three  to  eleven  years  after  the  opera- 
tions. See  Transactions  American  Gynaeco- 
logical Society,  1891),  and  Byrne  using  only 
the  cautery.  The  author  feels  entirely  con- 
vinced, however,  that  the  radical  operation, 
and  performed  as  radically  as  possible,  is  the 
best  for  all  cases  in  which  the  deadly  dis- 
ease is  not  too  far  advanced  to  make  an 
extensive  operation  practicable. 

Drug  Treatment  for  Haemorrhage. — The 
tampon  will  be  available  and  useful  in  some 


278  THE  MENOPAUSE. 

cases,  and  so  will  the  astringent  drugs  er- 
got, hydrastis,  antipyrine,  iron,  iodine,  alum, 
etc.  The  first  two  of  these  are  to  be  given 
in  sufficient  quantities  by  mouth,  and  the 
author  has  frequently  given  them  in  com- 
bination. The  othei's  are  to  be  used  local- 
ly in  the  vagina  or  uterus,  or  both.  If 
they  are  introduced  into  the  uterine  canal, 
it  is  better  to  moderately  dilate  it  first  as 
the  drug  will  thereby  be  absorbed  in  greater 
quantity  and  with  correspondingly  greater 
efficacy. 

Nerve  Lesions  of  the  Menopause  are  main- 
ly of  the  Sympathetic  System. — The  mental 
disease  which  has  been  considered  in  a 
previous  chapter  as  an  accompaniment  of 
the  menopause  is  in  many  cases  but  an- 
other manifestation  (or  perhaps  a  deriva- 
tive) of  vasomotor  disturbance.  In  fact 
the  purely  cerebro-spinal  lesions  of  the 
menopause  are  rare  compared  with  those  of 
the  sympathetic  system.  The  insanity  of 
the  menopause  then  is  frequently  due  to 
cerebral  congestion,  and  hence  the  greatest 


TREATMENT.  279 

benefit  may  sometimes  be  derived  in  such. 
cases  from  depletive  measures. 

Depletive  Measures  in  Nerve  Complica- 
tions.— They  may  be  used  in  the  following 
order :  First,  salines,  until  purging  has  been 
sufficiently  free ;  second,  vaginal  tampon 
soaked  in  glycerin ;  third,  abstraction  of 
blood  from  the  uterus  or  from  the  veins  of 
the  arm  or  leg.  It  is  astonishing  how 
quickly  relief  will  come  in  some  cases  from 
such  treatment.  Other  treatment  for  the 
insane  will  readily  suggest  itself  in  the  form 
of  careful  diet  and  hygiene,  avoidance  of 
care  and  worry,  if  possible,  cheerful  sur- 
roundings, occupation  which  shall  be  divert- 
ing but  not  fatiguing.  We  have  the  testi- 
mony of  Merson  and  other  alienists  who 
have  been  quoted  that  the  prognosis  of  the 
mental  disease  of  the  menopause  is  often 
very  good. 

No  Special  Treatment  is  Indicated  for 
the  Nerve  Lesions  of  the  Menopause. — The 
author  has  no  particular  treatment  to  rec- 
ommend as  especially  efficacious  for  the 


280  THE  MENOPAUSE. 

neuralgias,  paralyses,  hysterias,  and  epilep- 
sies of  the  menopause.  They  are  merely 
incidents  in  its  course  and  require  the  same 
treatment  which  would  be  indicated  were 
the  menopause  not  present.  Therefore  the 
reader  is  referred  to  the  special  treatises 
upon  nervous  diseases,  or  to  those  upon  gen- 
eral medicine,  to  Ross,  Hammond,  Gowers, 
Striimpell  or  other  reliable  authorities  for 
information  upon  this  subject. 

Treatment  of  Cutaneous  Complications 
External  and  Internal.  —  The  cutaneous  le- 
sions which  are  so  often  met  with  during  the 
menopause  are  wont  to  have  a  very  direct 
relation  to  it.  Some  of  them  have  already 
been  referred  to  in  connection  with  the  treat- 
ment of  vasoniotor  disturbances.  The  acne, 
urticaria,  erythema,  and  other  morbid  con- 
ditions of  the  skin  are  almost  always  sus- 
ceptible of  relief,  and  the  treatment  should 
consist  of  both  external  and  internal  meas- 
ures. Itching  surfaces  may  be  bathed  with 
a  solution  of  bicarbonate  of  soda  or  lime 
water.  If  caused  by  a  discharge  from  the 


TEEATMENT.  281 

vagina  the  latter  must  be  stopped  before 
the  itching  will  disappear.  The  indication 
is  for  astringents,  and  the  author  is  in  the 
habit  of  using  a  vaginal  tampon  moistened 
with  glycerite  of  tannin— 

$  Acidi  tannici 3j 

Glycerinae §j 

— or  with  a  solution  of  silver  nitrate,  thirty 
or  even  sixty  grains  to  the  ounce,  or  with 
a  two-per-cent  solution  of  icthyol  in  glyc- 
erin. The  condition  of  the  stomach  and 
bowels  must  also  be  interrogated  and  pur- 
gatives given  if  required.  The  abstraction 
of  blood  in  the  manner  referred  to  will 
also  be  helpful  with  some  of  the  cases  in 
which  the  skin  furnishes  elements  of  com- 
plication. 

Nothing  new  is  offered  for  the  compli- 
cations which  affect  the  kidneys,  eyes,  liver, 
spleen,  alimentary  canal,  etc.  Since  they 
are  usually  incidental  and  not  characteristic, 
they  should  be  treated  in  accordance  with 
the  principles  which  would  govern  their 
treatment  apart  from  the  menopause.  The 


282  THE  MENOPAUSE. 

works  on  general  medicine  are,  of  course,  to 
be  consulted  with  reference  to  their  treat- 
ment. 

There  is  little  additional  which  can  be 
said  in  regard  to  the  general  treatment  of 
those  who  are  passing  through  the  meno- 
pause. Those  who  are  not  sick,  but  think 
they  are,  must  be  disillusioned  with  gentle- 
ness but  firmness.  They  must  be  assured 
that  the  process  is  a  physiological  one 
through  which  the  great  majority  of 
women  pass  unharmed ;  and  yet  the  un- 
usual sensitiveness  of  both  body  and  mind 
at  this  juncture  must  be  fully  recognized 
and  proper  caution  enforced  against  all 
means  which  could  destroy  the  sensitive 
equilibrium.  Those  who  are  sick  must  be 
treated  upon  rational  principles,  not  by 
superstition  or  tradition;  surgical  conditions 
should  be  recognized  promptly  and  prompt- 
ly treated;  and  those  which  are  susceptible 
of  relief  by  drugs  should  receive  remedies 
which  are  tried  and  reliable,  not  the  nos- 
trums and  cure-alls  of  the  quacks. 


TEEATMENT.  283 

ADDENDA. 

CIIERON.  Traitemeut  des  Ecoulements  nevral- 
giques  de  I'Uterus  apres  la  Menopause.  Revue  medico- 
chirurgique  des  Maladies  des  Femmes,  Paris,  1890,  xii, 
383. 

LIEGEOIS.  Les  Sueurs  de  1'Age  critique,  leur 
Traitemeut  par  le  Sulfate  d'Atropine.  Revue  medi- 
cale  de  1'Est,  Nancy,  xi,  p.  4GO. 

SUSSDORFF.  On  Radical  Treatment  of  Local  Dis- 
ease at  the  Menopause.  New  York  Medical  Record, 
*iv,  p.  486 

HOUZEL.  Influence  of  Sea  Baths  on  Menstrua- 
tion. Congres  d'hydrotherapie  marine,  1894. 


INDEX   OF   AUTHOKS. 


Alibert,  221. 
Andral,  72. 
Avicenna,  117. 

Baker,  277. 

Baker  Brown,  238. 

Baldwin,  224. 

Bar!  6,  40. 

Barnes,  218. 

Baron,  40. 

Battey,  100,  218,  238,  239,  240, 

248,  249,  259. 
•  Bax,  227. 
Bedford,  24. 
Beech  er,  189. 
Binsenger,  98. 
Birkett,  78,  85. 
Bloom,  227. 
Boivin,  24,  81. 
Borner,  10,  52,  68,  97, 100, 133, 

268,  269. 
Brett,  220. 

Braxton-Hicks,  190,  216,  218. 
Brierre  de  Boismont,  100,  220. 
Bruant,  229. 
Bruntzel,  266. 
Buckel,  53. 
Bucknill,  215. 
Buffon,  12. 
Bureau,  72. 
Byrne,  277. 


Campbell,  228. 
Cazenave,  220. 
Cheron,  283. 
Chiari,  81. 
Clarke,  24. 
Clay,  238. 
Clement,  223,  224. 
Coe,  228. 

Conklin,  210,  227. 
Cortajarena,  135. 
244.    Courty,  100,  221. 
Cuvier,  12. 


Ballon,  43,  50,  55,  56,  111,  181. 

Danlos,  221. 

Bawson,  58. 

Beligny,  220. 

Bemocrates,  6. 

Be  Eedondo,  40. 

Be  Se"re,  39. 

Beshayes,  43. 

Bewees,  24. 

Biihrssen,  256. 

Bupuytren,  24. 

Ehrenberg,  12. 
Eliot,  228. 
Engelmann,  4,  229. 
Esquirol,  207. 
Exner,  53. 
285 


203. 


286 


INDEX  OF  AUTHORS. 


Farrc,  87. 

Jacobi,  M.  P  ,  4. 

Faye,  97. 

Jacquemier,  221. 

Felty,  39. 

Jaggard,  227. 

Fothergill,  24. 

James,  8. 

Frank,  203. 

Jenks,  40. 

Joal,  228. 

Galen,  80. 

Johustone,  39,  68,  126,  255. 

Garat,  228. 

Gardanne,  9. 

Kammerer,  58. 

Geber,  228,  272. 

Kaposi,  220. 

Glacvecke,  246,  256. 

Kehrer,  266. 

Goodell,  40,  218. 

Keith,  238. 

Gordon,  69,  255,  256 

Kennedy,  40,  268. 

Goth,  98. 

Kisch,  10,  18,  43,  50,  51,  57,  96,  99, 

Gowers,  280. 

101,  133,  202,  200,  224,  227,  228, 

Grellcty,  219,  220.     ' 

229,  235. 

Griesinger,  207,  208. 

Kiwisch,  52. 

Grisolle,  220. 

Kleinwachter,  265. 

Groedel,  224. 

Klob,  58,  72,  234. 

Gros,  227. 

Kobelt,  88. 

Gross,  78,  85,  88. 

Kolliker,  72. 

Guenau  do  Mussy,  227. 

Kora,  68. 

Guibout,  220. 

Krafft-Ebbing,  24. 

Guislain,  207. 

Krieger,  43,  52. 

Gusserow,  84,  269. 

Krishaber,  238. 

Guy,  39. 

Kriiger,  235. 

Kundrat,  4. 

Hammond,  280. 

Hannover,  98,  134. 

Landouzy,  24. 

Hardy,  220. 

Larousse,  15. 

Hegar,  52,  56,  67,  203,  205,  229, 

Laurans,  117. 

238,  239,  250,  251,  266. 

Lebert,  78,  85. 

Hensen,  87. 

Lecorche,  111. 

Heschl,  72. 

Leopold,  4. 

Higgins,  222. 

Leroy  de  Mericourt,  220. 

Hippocrates,  8,  117. 

Leudet,  96,  132,  133. 

His,  53. 

Lever,  281. 

Hoeflerus,  117. 

Lidgeois,  272,  283. 

Hoffman,  8. 

Lieven,  98,  134. 

Hoist,  68. 

Lisfranc,  24. 

Houzel,  283. 

Manton,  227. 

Ivanotf,  227. 

Martiueau,  220. 

INDEX  OF  AtJTHORS. 


287 


Mary,  196. 

Piron,  43,  101. 

Matusch,  216. 

Pliny,  239. 

Mayer,  97,  99,  134,  217,  235,  268. 

Potain,  221. 

Mayer,  L.,  207. 

Prochownik,  266. 

McDowell,  238. 

Puech,  43,  52,  88. 

Meigs,  24. 

Meissner,  24. 

Queirel,  98. 

Menville,  9. 

Mercier,  163. 

Kaciborski,  12,  40. 

Merson,   204,   207,   213,   214,   215, 

Eayer,  220. 

279. 

Eeinl,  40. 

Meynert,  24,  205. 

Eenaudier,  43. 

Miles,  39. 

Eicord,  228,  274. 

Montgomery,  265. 

Eobinson,  39. 

Moliere,  199. 

Eodsewitch,  98,  268. 

Moon,  224. 

Rohe,  215,  218,  219,  227. 

Morel,  207. 

Kokitansky,  72. 

Moricke,  4. 

Ross,  192,  280. 

Moses,  6. 

Eousseau,  189. 

M  filler,  84,  186. 

Rouvier,  98. 

Munde,  39. 

Royle,  101. 

Nelson,  228. 

Saint-Hilaire,  12. 

Nettler,  40. 

Stinger,  72. 

Neumann,  101. 

Saucerotte,  24. 

Norton,  101. 

Savage,  228. 

Nowlin,  5. 

Scanzoni,  78,  85,  200,  202,  268. 

Schlager,  207. 

O'Connor,  39. 

Schlichting,  100. 

Odebrecht,  265. 

Schorler,  269. 

Olive,  185. 

Simpson,  72,  111. 

Ollive,  227. 

Sims,  238. 

Orfila,  268. 

Skae,  207,  208,  209. 

Ormiere,  266. 

Skene,  210. 

Slavjansky,  53,  69. 

Pages,  229. 

Smith,  39. 

Paracelsus,  6. 

Stephenson,  40. 

Pean,  266. 

Stocquart,  186. 

Peaslee,  238. 

Stokes,  224. 

Petit,  113,  114,  229. 

Stolz,  223. 

Petrequin,  268. 

Strojnowski,  52,  112. 

I'll  Tiger,  87. 

Strum  pell,  280. 

Phillip,  196. 

Sampler.  101. 

288 


INDEX  OF  AUTHORS. 


Sussdorff,  283. 
Sutherland,  211,  268. 
Sutton,  69. 

Tait,  112, 186,  238,  240,  250,  269. 

Tarnowski,  40. 

Taufter,  266. 

Thomas,  39,  56,  206. 

Tilt,  9, 10, 14,  17,  21, 40,  65,  97, 133, 

208,  238. 
Tissier,  266. 
Tissot,'24. 
Tuke,  215. 

Vanderkolk,  215. 


Van  de  Warker.  159, 160. 
Veit,  88. 

Yelpeau,  24,  78,  85. 
Virchow,  72,  85. 

Waldeyer,  52. 
Wells,  238. 
Werth,  229. 
Willette,  229. 
Williams,  4,  39,  68. 
Winiwartcr,  78,  85. 
Wyder,  4. 
Wyman,  40. 

Ziemssen,  272. 


INDEX. 


Abdominal  section,  261. 

Abnormal,  attention  aroused  by 
the,  14. 

Abortion,  consequences  of,  36. 
from  sudden  impressions,  168. 

Abscess  resulting  from  disease  of 
.  the  uterus,  171. 

Absence  of  corpora  lutea,  181. 

Abstinence,  155, 156. 
sexual,  166. 

Abstraction  of  blood  for  conges- 
tion of  the  pelvic  organs,  273, 
274. 

of  blood  from  the  uterus,  279, 
281.      ' 

Abundant  discharge  of  urine,  194. 

Accessory  ostia  of  the  Fallopian 
tubes,  255. 

Accidental  influences  of  the  men- 
opause, 93,  167. 

Acne,  280. 

Acute  diseases  which  may  induce 
the  menopause,  234. 

Adenomata  of  the  uterus,  74. 

Adhesions  as  a  means  of  sustain- 
ing nutrition,  115. 

Age  as  an  influence  of  the  meno- 
pause, 92,  93,  102. 
limit,  conclusion  as  to,  102. 
of  the  menopause,  table  show- 
ing the,  94,  96-98. 


Age  when  the  phenomena  of  th  e 

menopause  occur,  28. 
Alienists,  279. 
Alimentary  canal,  281. 
diseases  of  the,  177. 
Alum,  278. 

Ambiguity  in  various  terms,  2. 
Amenorrhoea,  118. 

conservatism  of,  233. 
Amyloid  disease,  234. 

of  the  uterus,  71. 
Anaemia,  244. 
cerebral,  204. 

during  the  menopause,  196,  201. 
significance  of,  196. 
sufferers  from,  36. 
Analogue  of  menstruation  in  ani- 
mals, 11,  12. 
of  the  menopause  wanting  in 

animals,  12. 

Anatomical  changes  due  to  inflam- 
mation, 84. 
changes  in  the  Fallopian  tubes, 

vagina,  and  clitoris,  62. 
changes  in   the   genital  organs 
leading  to  the  menopause,  66. 
changes  in  the  ovaries,  42,  52. 
changes  in  the  ovaries,  accord- 
ing to  Dalton,  43. 
changes  in  the  uterine  mucous 
membrane,  7. 


20 


289 


290 


INDEX. 


Anatomical  changes  in  the  uterus, 

53,  55. 

changes  incidental  to  the  meno- 
pause, 78. 

changes  of  traumatic  or  infec- 
tious origin,  84. 

changes  resulting  from  the  men- 
opause, 42. 

changes    which      produce    the 
menopause,  42. 

Ancient  writers  on  menstruation 
and  the  menopause,  7. 

Anteflexkm  of  the  uterus,  21. 

Antipyrine,  278. 

Aperients,  213. 

Apoplexy,  22. 

Apparent  menopause  occurring 
prematurely,  262. 

Appendages,  removal  of  the,  does 
not  always  cure  pain  and  neu- 
ralgia, 259. 

Appetite,  loss  of,  195. 

Areolar  hyperplasia,  79. 

Arrest  of  the  monthly  discharge,  1. 

Artificial  menopause,  247. 
production  of   the  menopause, 
indications  for  the,  240. 

Ascitic  accumulations,  121. 

Assimilation,  faults  of,  30. 

Asthenopia,  222. 

Asthma,  223. 

Astringent  drugs,  278,  281. 

Atmospheric  influence  on  the 
menstrual  function  varies, 
131. 

pressure,  varying  effects  of,  136, 
138. 

Atopomenorrhcea,  246. 

Atresia  of  the  cervical  canal,  56. 
of  the  uterine  canal,  75. 
of  the  vagina,  75,  76. 

Atrophic  changes  are  uniform  in 
the  natural  menopause,  86. 


Atrophic,  changes  of  the   meno- 
pause are,  16,  86. 
Atrophy,  204,  275. 
due  to  excess  of  function,  115, 

116. 

of  structure,  5,  41. 
of  the  cervix,  56. 
of  the  clitoris,  63. 
of  the  external  genitals,  63. 
of  the  genital  organs,  246. 
of  the  mammary  glands,  64. 
of  the  organs  of  generation  from 

pressure,  122. 
of  the  ovaries,  247. 
of  the  ovaries  due  to  diabetes.  52. 
of  the  ovaries  precedes  atrophy 

of  the  uterus,  52,  56. 
of  the  uterus,  59-61,  256. 
of  the  uterus  and  ovaries  from 

diabetes,  112. 
producing  the  menopause  may 

be  primary  or  secondary,  115. 
Atropia  sulphate  for  the  sweating 

of  the  menopause,  272. 
Aura  of  epilepsy,  192. 
Author's    experience    concerning 

the  menopause,  19. 

Bathing,  273. 

Baths,  salt  water,  273. 

Bereavement,  213. 

Bicarbonate  of  soda,  280. 

Biliousness,  195. 

Blending  of  sexual  types,  251. 

Blood,  abstraction  of,  273,  274,  279. 

coagulability  of  the,  200,  201. 

discharge  of,  4. 

increase  in  the  tension  of  the,  31- 

poverty  of  the,  196. 
Brain  lesion,  244. 

organic  disease  of  the,  214. 
Breast,  malignant  disease  of  the, 
78. 


INDEX. 


291 


Breast,  skin  lesions  of  the,  220. 
Bronchitis,  223. 

Caesarean  section,  243. 

Canal,  uterine,  4. 

Cancer,  association  of,   with  the 

menopause,  198. 
high  amputation  of  the   cervix 

for,  277. 

of  the  uterus,  209,  277. 
radical  measures  indicated  for, 

277. 
statistics  from  the  United  States 

census  of  1880,  23. 
Carcinoma  mammae,  22. 

uteri,  21,  22,  269. 
Cardiopathies.  223. 
Castration,  239. 

Caustics,    injury  to    the    uterine 
mucous  membrane  from,  71. 
Cautery,  277. 
Cerebral  anaemia,  204. 

congestion,  142,  204,  278. 
Cerebro-spinal  lesions,  278. 
Cervix,  degeneration  of  the,  57. 
during  the  menopause,  57. 
high    amputation    of    the,    for 

cancer,  277. 

Cessation  of  the  flow,  246. 
Change  of  life,  2, 10. 
Changes  in  animals  after  the  ces- 
sation of  ovulation,  251. 
in  eunuchs,  261. 

structural,  in  the  body  in  gen- 
eral, 66. 

Childbearing,  157. 
frequent,  210. 
function,  3. 

no  burden  to  certain  women,  146. 
normal  function  of,  147. 
Chilliness  of  the  extremities,  194, 
Chloasma,  '220. 
Chronic  endometritis,  247. 


Chronic    inflammatory    processes 
leading  to  the  menopause,  108. 
inflammatory  processes,   varie- 
ties of,  109. 
oedema,  219. 

parenchymatous  metritis,  79. 
visceral  diseases,  244. 
Civilized  life  preferable  to  savage 

189. 

Climacteric,  2,  204-206. 
diabetes,  112. 
disease,  2, 179. 
insanity,  207-209,  210,  212-214, 

216,  272. 

phenomena  of  the,  5,  24. 
psychoses,  215. 
Climate  as  an   influence  of  the 

menopause,  28,  92, 131. 
effect  of,  in  producing  the  meno- 
pause prematurely,  231. 
effect  of,  upon   the  menstrua- 
tion, 135. 

Climatic     surroundings,    adjust- 
ment to,  138. 

Climatology,  relation  of,  to  gynae- 
cology, 139. 
Clitoris,    anatomical    changes    ill 

the,  62,  64. 
atrophy  of  the,  63. 
Coagulability   of  the  blood,  200, 

201. 

Coitus,  157. 
effects  of,  when  senile  changes 

have  occurred,  64. 
with  menstruating  women  for- 
bidden, etc.,  7. 
Compensations    in  civilized    life, 

189. 

Conception,  influence  of  the  men- 
opause upon,  180. 
prevention  of,  160. 
Concomitants  of  the  menopause, 
29. 


292 


INDEX. 


Congestion,  274. 
cerebral,  204,  278. 
of  the  genital  organs  in  men- 
struation, 11. 

of  the  pelvic,  organs,  194,  273. 
of  the  uterus  in  the  early  stages 

of  the  menopause,  56. 
Consequences    of   arrest    of    the 

menses,  71. 

Considerations  concerning  the  or- 
gans of  the  genital  apparatus, 
41. 
Constipation,  sufferers    from,  36, 

194,  195,  223. 
Convalescence,  211. 
Cooks,  154. 

Corpora  lutea,  absence  of,  181. 
Corpus  luteum,  report  on  the,  43. 

uteri,  degeneration  of  the,  57. 
Crises,  vasomotor,  29. 
Critical  time,  2, 198,  270. 
Cruelty,  213. 
Cure-alls,  282. 
Currents,  radiating,  of  ganglion- 

ic  centers,  5. 
Curettage,  276. 

Cutaneous    complications,    treat- 
ment of,  280. 
lesions,  280. 

Data  concerning  the  menopause, 

11. 
Decidua  provided    each    month, 

148. 

Decidual  endometrium,  199. 
Defective     development,     meno- 
pause from,  118,  119. 
development  of  the  genital  or- 
gans, 265. 

Definition  of  the  menopause,  1. 
of  menstruation,  4. 
of  menstruation,  deduction  from 
the,  4. 


Degeneration,  fatty,  275. 

of  structure,  41,  62. 

of  the  cervix  and  corpus  uteri,  57. 

of  the  endometrium,  31. 
Degenerative  changes  due  to  old 
age,  225. 

changes  in  thesexual  organs,215. 
Delusions,  209,  215. 
Dementia,  211. 
Demonomania,  209. 
Depletive  measures,  279. 

measures    in    nerve    complica- 
tions, 279. 

Deposits  of  pigment,  220. 
Depression,  194,  209,  214,  215. 
Derangement  of  the  function  of 

the  lungs,  226. 

Destruction  of  the  genital  organs, 
85, 130, 

of  the  mammary  glands,  85. 
Diabetes,  cessation  of  the  menses 
in,  111. 

climacteric,  112. 
Diarrhoea,  194, 195,  225. 
Diathesis,  26. 
Diet,  210. 

Different  effects  of  climate,  135. 
Digestion  compared  with  the  men- 
opause, 17. 

consciousness  of,  13. 

faults  of,  30. 
Disappearance  of  the  menses  from 

kidney  lesions.  111. 
Disappointment  in  love,  214. 

sufferers  from,  36. 
Discharge  from  the  vagina,  280. 
Disease,  acute  inflammatory,  104. 

and  traumatism,  93, 102, 103. 

of  the  heart,  214,  224. 

organic,  210. 

psychical,  208. 

variety  of,  involving  the  ovaries, 
67. 


INDEX. 


293 


Disillusioned,  282. 

Disorders,  chronical,  8. 
digestive,  31. 

Disposition   determines   the  phe- 
nomena of  the  menopause,  191. 
influence  of  the,  upon  the  men- 
opause, 151. 

Disturbance,  emotional  and  intel- 
lectual, 215. 

Dizziness,  205. 

Dodging  time,  2. 

Domestic  unhappiness  from  ster- 
ilization, 256. 

Douches,  vaginal,  274. 

Drug  treatment  for  haemorrhage, 
277. 

Duration  of  climacteric  insanity, 

212. 
of  the  menopause,  95. 

Dyscrasia,  26. 

Dysmenorrhoea,  239,  242,  252. 
suiferers  from,  36, 154. 

Dyspepsia,  223. 

Dyspnoea,  224. 

Eczema  genitalium,  220. 
Edinburgh  Royal  Asylum,  209. 
Egyptians,  interpretation  of  men- 
struation by  the,  6. 
Electricity  for  the  relief  of  pai^ 

259. 

treatment  with,  249. 
Embolism,  72. 
Emile,  189. 

Emotional    and   intellectual    dis- 
turbance, 215. 
Endometrial    tissue,    friability   of 

the,  200. 

Endometrium,  276. 
decidual,  199. 
degeneration  of  the,  31. 
granulations  of  the,  59. 
haemorrhage  from  the,  37. 


Endometritis,  chronic,  247. 

in  prostitutes,  162. 
Enlargement,  myomatous,  of  the 

uterus,  31. 
Epilepsy,  204,  243,  280. 

aura  of,  192. 

Equilibrium,  sensitive,  282. 
Ergot,  278. 
Erythema,  219,  280. 
Eskimos,  136. 
Eunuchs,  physical  changes  which 

occur  in,  261. 

Evils  of  the  menopause  exagger- 
ated, 188. 
Evolution,    Darwin's    theory    of 

139. 
Exaggerated  views  concerning  the 

menopause,  16. 
Exanthemata,  234. 
Excess,  sexual,  155,  156. 
Excesses,  venereal,  36. 
Excessive  sexual  indulgence,  234., 

235. 
Excessively      fertile,      premature 

menopause  in  the,  235. 
Experience  of  stock  breeders,  158. 
Exposure,  results  of,  36. 
External  genitals,  atrophy  of  the, 

63. 
Eyes,  281. 

Factors  influencing  the  advent 
and  progress  of  the  meno- 
pause, 89,  92. 

Fall  and  injury  of  the  head,  214. 
Fallopian  tube,  accessory  ostia  of 

the,  255. 
tubes,    anatomical    changes    in 

the,  62,  66. 
Family  peculiarities,  140. 

taint,  141. 

Fatty  degeneration,  275. 
degeneration  of  the  uterus,  72. 


294 


INDEX. 


Fatty  degeneration  of  the  uterus, 

varieties  of,  72. 
Fear  of  losing  the  soul,  209. 
Fermentation,  intestinal    or   gas- 
tric, 195. 
Fertility  and  sterility  are  relative 

terms,  143. 
and  sterility,  bearing  of,  upon 

the  menopause,  143. 
excessive,  146, 172. 
may    hasten    the    menopause, 

144. 

Fever  and  inflammation,  214. 
Fevers    which    may    induce    the 

menopause,  234. 
Fibro-cystic,  269. 
Fibroids,  247. 

uterine,   may  defer  the  meno- 
pause indefinitely,  129. 
Fibroma  uteri,  21,  22. 
Financial  trouble,  213. 
Flashes  of  heat,  245,  272. 
Flatulence,  195. 
Flow,  cessation  of  the,  246. 

menstrual,  5. 
Flushing,  246. 

Friability  of  the  endometrial  tis- 
sue, 200. 
Fright,  214. 
Fruition  in  the  vegetable  world, 

41. 

Function,  childbearing,  3. 
menstrual,  cessation  of  the,  1,  3. 
of  menstruation,  4. 
Functional  activity  at  the  begin- 
ning of  the  menopause,  91. 
troubles  of  the  menopause,  30. 
Functions  painless  under  normal 
conditions,  13. 

Galvano-cauterization,  276. 
Gastro-intestinal  canal,  273. 
intestinal  disturbances,  194. 


General    changes    in    the    early 

stages  of  the  menopause,  91. 
congestion  in  the  early  stages  of 

the  menopause,  91. 
paralysis,  113,  204. 
Genital  organs,  congestion  of  the, 

273,  274. 
organs,  defective    development 

of  the,  265. 

Glands,  congestion  of  the,  65. 
mammary,  changes  in  the,  64, 

65. 

Glandular  discharge  from  the  ute- 
rus, 59,  61. 
disorders,  220. 
secretion,  4. 
Glycerin,  281. 
Glycerite  of  tannin,  281. 
Gonorrhoea,  effect  of  latent,  upon 

newly  wedded  women,  107. 
influence  of,  in    inducing    the 

menopause,  236. 
in  prostitutes,  163. 
Granulations  of  the  endometrium, 

59. 

Greeks,    interpretation    of    men- 
struation by  the,  5. 
Gulping,  195. 
Gurgling,  195. 
Gynaecologist,  210. 
Gynaecology  has  given  importance 
to  the  premature  menopause, 
230. 

Habits,  50. 
Haemoptysis,  138. 
Haemorrhage  as  influenced  by  at- 
mospheric conditions,  138. 
drug  treatment  for,  277. 
during  the  menopause,  124. 
from  exuberant  nutrition  of  the 

endometrium,  79. 
from  the  endometrium,  37,  59. 


INDEX. 


295 


Haemorrhages  from  the  uterus,  269. 
menopause-uterine,  275. 
of  the  menopause,  197, 198. 
of  the    menopause  at  long  or 

short  intervals,  198, 199. 
of  the  menopause,  conditions  of 

the  blood  iu,  200. 
of  the  menopause  demand  ac- 
tive treatment,  201. 
of  the  menopause,  different  con- 
ditions of,  from  those  of  ordi- 
nary menstruation,  200. 
of  the  menopause    from  vaso- 

motor  paralysis,  275. 
of  the  menopause,  theories   of 
Frank,    Hegar,    Kisch,    and 
Scanzoni,  202,  203. 
profuse,  2(59,  274. 
substitutional,  246. 
uterine,  214,  253. 
uterine,  not  always  checked  by 

the  menopause,  128. 
Haemorrhoids,  223. 
Hallucinations,  206,  214,  215. 
Headache,  194. 

sufferers  from,  36. 
Health,  state  of  the,  as  a  factor  in 

inducing  the  menopause,  28. 
Heart  disease,  22,  214 
Heat  flashes,  96, 139, 193, 194. 
Hemicrania,  206. 
Hemiplegia,  '22. 

Hereditary  and  degenerative  neu- 
roses, 216. 
Heredity  as  an  influence  of  the 

menopause,  93. 

habit,  and  function,  effect    of, 
in  producing  the  menopause 
prematurely,  232. 
Hernia,  ventral,  254. 
Heteroplasia,  26. 

High  amputation  of  the  cervix  for 
cancer,  277. 


Hindus,  133. 
Histology,  3. 
Homicidal  and  suicidal  impulse, 

209. 
Humoral    pathologists,    belief  of 

the,?. 

Hydrastis,  278. 

Hydrometra  from  stenosis,  57. 
Hymen,  120. 

Hyperaeniia  of  the  vagina,  62. 
Hyperaesthesiae,  205,  214. 
Hyperkinesiae,  205. 
Hyperplasia,  areolar,  79. 
Hypogastric  plexus,  5. 
Hysterectomy,  277. 

without  interruption  of  the  men- 
strual history,  75. 
Hysteria,  142, 192. 

during  the  menopause,  30. 

Icthyol,  281. 

Ignorant  inactivity,  270. 

Ill  health  and  want,  214. 

Importance  of  the  menopause  in 
the  light  of  recent  develop- 
ments, 11. 

Impulse,  suicidal  and  homicidal, 

209. 
to  reproduction,  11. 

Increase  of  the  blood  tension,  31. 

Incurability  of  subjects  with  vi- 
cious habits,  249. 

Indians,  peculiarities  of.  141. 

Indications  for  the  artificial  pro- 
duction of  the  menopause.  240. 

Indigestion,  195. 

Induction  of  the  menopause,  care 
in  selecting  cases  for  the,  240. 

Infection  as  a  cause  of  changes  in 
the  uterine  mucous  mem- 
brane, 71. 

in  connection  with  latent  gonor- 
rhoea, 107. 


296 


INDEX. 


Infectious  inflammatory  processes, 

106. 

Inflammatory  processes  unasso- 
ciated  with  the  puerperal  con- 
dition, 106. 

Influence  of  the  different  genital 
organs  in  the  induction  of  the 
menopause,  240. 

Influence  of  wasting  diseases,  232. 
Inheritance,  influence  of,  152. 
Insanity,  22,  24,  38,  211,  212,  243, 

244. 

at  the  change  of  life,  212. 
climacteric,    207-210,    212-214, 

216,  272. 

of  the  menopause,  38,  210,  278. 
relation   of  the  menopause  to, 

211. 
resulting     from    nervous     and 

mental  trouble,  31. 
Insomnia,  209. 

Intellectual  derangement,  214. 
Intemperance,  214. 
Intense  impressions  may  bring  the 

menopause,  168, 169. 
Intermenstrual  intervals,  15. 
Intermittent  fever,  234. 
Intestinal  or  gastric  fermentation, 

195. 

Intramural  myomata,  74. 
Iodine,  278. 
Iron,  278. 

Irregular  and  unwomanly  occupa- 
tion, 153. 
bleeding,  269. 
sweating,  246. 
Irregularities   in   the    menopause 

from  diseased  organs,  86. 
Irritability,  nervous,  204. 
of  disposition  during  the  meno- 
pause, 30. 
Ischa-rnia,  72. 
Itching,  280,  281. 


Jaundice,  223,  225. 
Jewesses,  peculiarities  of,  141. 

Kidneys,  281. 

disease  of  the,  causing  disap- 
pearance of  the  menses,  111. 

Labia  minora,  64. 
Lactation,  210. 

effect  of  prolonged,  77. 
Laundresses,  154. 
Lesion,  brain,  244. 

cerebro-spinal,  278. 
Lesions  attributable  to  old    age, 
224,  225. 

of  the  mind  and  nervous  sys- 
tem, 204. 
Leucorrhcea,  246. 

of  the  menopause,  19. 
Life,  change  of,  2,  10. 
Lime  water,  280. 
Listlessness,  209. 
Loss  of  appetite,  1 95. 
Lungs  and  kidneys,  wasting  dis- 
eases of  the,  110. 

derangement  of  the,  226. 

Malignant  disease,  269. 

disease,  destructive  character 
of,  81. 

disease  following  the  meno- 
pause and  attributed  to  it,  82. 

disease,  increased  vascularity 
with,  124. 

disease,  the  menopause  does  not 
necessarily  favor,  197. 

disease  of  the  breast,  78. 

disease  should  not  be  allowed 
to  reach  the  irremediable 
stage,  82. 

disease  simulated  by  fibroid  tu- 
mors of  the  uterus,  83. 

disease,  small  percentage  of 
cases  of  at  the  menopause,  197. 


INDEX. 


297 


Malignant  disease,  total  number  of 
cases  of,  82. 

growths,  121,  122. 
Mammary    glands,    changes     in 
the,  64. 

glands,  destruction  of  the,  85. 

glands,  influence  of  the,  upon 
the  menstrual  function,  76. 

glands,  neoplasms  of  the,  77. 
Mania,  38,  194,  211,  212. 
Mastodynia,  221. 

Melancholia,  38,  142,  211,  212,  215, 
247,  248,  260. 

of  the  menopause,  207-209. 
Meningo-encephalitis,  114. 
Menopause,  2,  3. 

abrupt  occurrence  of  the,  140. 

accidental  influences  of  the, 
93. 

accompaniments  of  the,  142. 

according  to  modern  writers,  9. 

age  for  the,  at  the  Oneida  Com- 
munity, 161. 

age  of  American  Indian  women 
at  the,  98. 

age  among  Hindus,  and  in  Nor- 
way, Kussia,  Denmark, -Ger- 
many, England,  and  France, 
133,  134. 

age  among  Danish,  English, 
French,  German,  Austrian, 
Norwegian,  and  Russian  wom- 
en, 96-98. 

age  dependent  upon  climate, 
etc.,  28. 

among  the  Shakers,  166. 

anaemia  during  the,  196. 

analogue  of  the,  absent  in  ani- 
mals, 12, 

anatomical  changes  coincidental 
with  the,  42. 

anatomical  changes  effected  by 
the,  41. 


Menopause,    anatomical    changes 

incidental  to  the,  78. 
anatomical  changes  resulting 

from  the,  42. 

anatomical  changes  which  pro- 
duce the,  42,  66. 
ancient  opinions  of  the,  not  well 

founded,  17. 

apparent,  occurring  premature- 
ly, 262. 

artificial,  131,  247. 
artificial  production  of  the,  239. 
as    a    complication  of   visceral 

diseases,  31. 
association  of  the,  with  cancer, 

198. 
atrophic  changes  more  uniform 

in  the  natural,  86. 
bearing  of  cancer  during  the,  32. 
bearing  of  coincidental  diseases 

upon  the,  31. 
bearing  of  fertility  and  sterility 

upon  the,  143. 
benign    neoplasms    developing 

simultaneously  with   the,  83. 
by  Borner,  10. 
by  Kisch,  10. 
careful  selection  of  cases  for  the 

induction  of  the,  240. 
changes  during  the,  16. 
changes  in  neoplasms  during 

and  after  the,  83. 
changes  in  the  outline  of  the 

body  during  the,  29. 
changes  in  the  uterus  during 

the,  58. 
changes  in    the    uterus  which 

produce  the,  70. 
changes   in  women  induced  by 

the,  41. 

changes  of  the,  are  atrophic,  86 
classification  of    experience   of 

the,  28. 


298 


INDEX. 


Menopause,  compared  with  diges- 
tion, 17. 

concomitants  of  the,  29. 

conservative  character  of  the,  81. 

considered  as  a  cause  of  dan- 
ger, 14. 

course  of  menstruation  and  the, 
in  the  sterile,  149. 

deferred,  254. 

definition  of,  1,  15, 

degeneration  of  neoplasms  after 
the,  84. 

development  of  neoplasms  after 
the,  84. 

diabetes  with  the,  112. 

due  to  the  pressure  of  neoplasms 
of  the  uterus,  73. 

due  to  traumatism,  108. 

duration  of  the,  95. 

early,  99,  253. 

from  disease  of  the  genital  or- 
gans, 164. 

not  necessarily  the  result  of 
early  puberty,  133. 

occurrence  of  the,  in  the  trop- 
ics, 233. 

erroneous  views  of  the  relation 
of  the,  to  haemorrhage,  128. 

establishment  of  the,  249. 

evils  of  the,  exaggerated,  188. 

exaggerated  views  concerning 
the,  lt>. 

experience  of  the  author  con- 
cerning the,  19. 

explanation  of  degenerative 
changes  during  the,  25. 

factors  which  influence  the  ad- 
vent and  progress  of  the, 
89,  92. 

fails  to  come  with  many  cases 
of  fibroid  disease,  129. 

faults  of  assimilation  with  the, 
30. 


Menopause,  faults  of  digestion 
with  the,  30. 

following  injuries  to  the  va- 
gina, 75. 

from  chronic  inflammatory  pro- 
cesses, 108. 

from  defective  development, 
118. 

from  excesses  in  alcohol  or 
venery,  265. 

from  excessive  childbearing, 
265. 

from  hard  work,  265. 

from  injuries,  236. 

from  obesity,  116,  265. 

from  removal  of  the  appendages, 
253. 

from  superinvolution,  77, 116. 

from  the  fortieth  to  the  fiftieth 
year,  28. 

from  the  sequela?  of  parturition, 
237. 

from  traumatism,  2S6. 

functional  activity  at  the  begin- 
ning of  the,  91. 

functional  troubles  of  the,  30. 

general  congestion  in  the  early 
stages  of  the,  91. 

general  paralysis  in  relation  to 
the,  113. 

haemorrhages  of  the,  37,  124, 
197,  202,  203. 

haemorrhages  of  the,  due  to  vaso- 
motor  paralysis,  275. 

hastened  by  destruction  of  the 
genital  organs,  85. 

hope  and  longing  for  the,  73. 

hysteria  of  the,  30. 

if  troublesome  may  intensify 
pre-existing  visceral  disease, 
38. 

incomplete  erroneous  ideas  con- 
cerning, 82. 


INDEX. 


299 


Menopause  indefinitely  deferred, 
87. 

indicates  completion  of  fruitful 
period,  41. 

indications  for  the  artificial  pro- 
duction of  the,  246. 

induced  by  obesity,  234. 

influence  of  age  upon  the,  92. 

influence  of  climate  upon  the,  92. 

influence  of  degenerative  pro- 
cesses upon  the,  115. 

influence  of  disease  and  trauma- 
tism  upon  the,  92. 

influence  of  the  peritonaeum 
upon  the,  70. 

influence  of  the  vagina  upon 
the,  75. 

influence  of  disposition  as  to 
the,  151. 

influence  of  heredity  upon  the, 
93. 

influence  of  menstrual  life 
upon  the,  152. 

influence  of  neoplasms  upon 
the,  120. 

influence  of  nervous  diseases 
upon  the,  112. 

influence  of  occupation  on  the, 
154. 

influence  of  race  upon  the,  35. 

influence  of  temperament,  hab- 
its, occupations,  and  social 
surroundings  upon  the,  93. 

influence  of  the  genital  organs 
in  the  induction  of  the,  240. 

influence  of  the,  upon  ovulation 
and  conception,  180. 

influence  of  tumors  of  the  ab- 
dominal viscera  upon  the,  7. 

influences  of  the,  vary  for  differ- 
ent women,  92. 

inherent  tendencies  in  individ- 
uals as  to  the,  151. 


Menopause  in  prostitutes,  161,  164, 
165. 

insanity  of  the,  38,210,  213,  278. 

insignificance  of  the,  with  many 
women,  142. 

irregularities  of  the,  from  dis- 
eased organs,  86. 

irritability  of  disposition  dur- 
ing the,  30. 

is  premature  prior  to  the  fortieth 
year,  252. 

Kisch's  analysis  of  500  cases  of 
the,  18. 

late,  100. 

lateness  of  the.  as  a  family  char- 
acteristic, 140, 

is  least  troublesome  in  women 
who  are  highly  developed 
physically  rather  than  men- 
tally, 12. 

lesions  of  the  mind  and  nerv- 
ous system  in  connection 
with  the,  204. 

lesions  of  the  skin  which  may 
accompany  the.  218. 

less  to  be  feared  as  knowledge 
concerning  it  increases,  25. 

malignant  degeneration  result- 
ing with  the,  32. 

malignant  disease  of  the,  22. 

may  be  established  suddenly  or 
gradually,  244. 

may  be  hastened  by  excessive 
fertility,  144. 

may  be  uneventful,  16. 

melancholia  of  the,  207,  208. 

mental  disease  of  the,  22. 

moderately  troublesome,  30,  36. 

modified  by  race  peculiarities, 36. 

mortality  during  the,  from  ma- 
lignant disease,  23. 

most  significant  among  highly 
bred  women,  13. 


300 


INDEX. 


Menopause,  neoplasms  of  the,  21. 

nerve  lesions  of  the,  278,  279. 

nervous  symptoms  of  the,  30, 205. 

neuroses  of  the,  24. 

new  foundation  for  the,  11. 

no  distinct  disease  of  the,  179- 

normal,  28,  35. 

not  carefully  observed  by  the 
ancient  writers,  7. 

not  induced  by  removal  of  the 
appendages  of  one  side,  253. 

not  necessarily  followed  by  ma- 
lignant disease,  197. 

not  responsible  for  degenerative 
changes,  26. 

observations  as  to  the  age  of  the, 
133. 

opinion  of  Larousse  concerning 
the,  15. 

organic  troubles  of  the,  30. 

ovarian  changes  of  the,  48. 

past  teaching  about  the,  erro- 
neous, 14. 

phenomena  of  the,  may  be  due 
to  bad  habits,  195. 

phenomena  of  the,  normal  and 
morbid,  187,  208. 

phenomena  of  the,  prolonged, 
37. 

phenomena  of  the,  varied,  15. 

physical  condition  of  women  at 
the  time  of  the,  27. 

premature.  112,  145,  230. 

premature,  caused  by  constitu- 
tional or  local  lesions,  231. 

premature,  effective  causes  of 
the,  232. 

premature,  factors  which  induce 
the,  233. 

premature,  from  exhaustion  of 
*the  vital  forces,  74. 

premature,  individual  factor  in 
the,  232. 


Menopause,  premature,  in  the  ex- 
cessively fertile,  235. 
premature,  phenomena  of  the, 

244,  245. 
premature,    substances     which 

may  induce  the,  234. 
premature,  surgically   induced, 

237. 
premature,      venereal      disease 

causing  the,  235. 
produced    by    removal    of   the 

ovaries,  240. 
production  of  the,  248. 
profuse  haemorrhage  during  the, 

274. 
prognosis  of  the  mental  disease 

of  the,  279. 
prolonged,  140,  267- 
regular,  267. 
relation  of  excessive  fertility  to 

the,  172. 
relation  of  malignant  disease  of 

the  pelvis  to  the,  80. 
relation    of   sexual   excess   and 

abstinence  to  the,  155. 
relation    of    the,    to    insanity, 

211. 
removal  of  the  uterus  to  induce 

the,  245. 
resulting  from  amyloid  disease, 

71. 

resulting  from   sudden  impres- 
sions, 108, 169. 
retarded,  267. 
retarded  by  neoplasms,  73. 
second  experience  of  the,  275. 
seldom   induced    by  disease  of 

the  tubes,  69. 

serious  lesions  of  the,  32,  38. 
severe  types  of  the,  37. 
sexual  abstinence  in  its  relation 

to  the,  166. 
sexual  ardor  of  the,  206. 


INDEX. 


301 


Menopause,  sexual  desire  in    its 
relations  with  the,  257. 

should  be  a  normal  function,  13. 

signifies  tissue  changes,  90. 

sometimes   results  in  ameliora- 
tion of  uterine  tumors,  128. 

statistics  concerning   the,  169- 
179. 

substitute  for  the  term,  2. 

surgically  induced,  131. 

sweating  of  the,  272. 

table  showing  the  age  of  the,  94. 

the  normal,  not  a  dangerous  ex- 
perience, 188. 

the  typical,  an   uneventful  ex- 
perience, 187. 

Tilt's  view  concerning  the,  17. 

time  required  for  the  changes  of 
the,  varies,  86. 

trauma  in  the  development  of 
the,  130. 

treatment  of  the,  271. 

uncomfortable,  caused  by  occu- 
pation, 153. 

uneventful,  271. 

unstable    equilibrium    of    the 
mind  at  the,  217. 

uterine  haemorrhages,  275. 

various  data  concerning  the,  11. 

venesection  for  the,  8. 

visceral  disturbances  of  the,  30. 

women  who  suffer  from  the,  271. 
Menses,  consequences  of  the  arrest 

of  the,  8. 
Menstrual  derangements,  205. 

disorder,  217. 

era,  prolongation  of  the,  favored 
l>y  outdoor  life,  132. 

flow,  5. 

flow,  abrupt  cessation  of  the,  245, 
247. 

flow  diminished    with   anaemia 
and  nervous  disease,  113. 


Menstrual  flow,  increase  of,  from 
malignant  growths,  122. 

fluid,  261. 

function,  264,  269. 

function,  abolition  of  the,  from 
disease  of  the  lungs  and  pleu- 
ra, 110. 

function,  abolition  of  the,  from 
traumatism,  107,  108. 

function,  abolition  of  the,  in  va- 
rious ways,  109. 

function,  brochure  on  the,  4. 

function,  cessation  of  the,  1. 

function  disturbed  by  infectious 
inflammatory  processes,  106. 

function,  early  exhaustion  of  the, 
136. 

function,  influence  of  fatty  de- 
generation of  the  uterus  upon 
the,  72. 

function,  influence  of  sea  air 
upon  the,  137. 

function,  influence  of  the  mam- 
mary glands  upon  the,  76. 

function,  influence  of  neoplasms 
of  the  mammary  glands  upon 
the,  77. 

function,  restoration  of  the, 
sometimes  possible,  110. 

function,  result  of  sensitiveness 
of  the,  102. 

history  uninterrupted  in  certain 
cases  of  hysterectomy,  75. 

life,  prolonged,  100. 

life,  stormy,  36. 

life,  unfavorable  influences  dur- 
ing the,  152. 

molimina,  246. 

period,  analogue  of  the,  in  ani- 
mals, 11. 

Menstruating  women  are  ceremo- 
nially unclean,  7. 
Menstruation,  abolition  of,  106. 


302 


INDEX. 


Menstruation,  abolition  of,  from 
diabetes,  111. 

abolition  of,  from  disease  of  the 
kidneys,  111. 

absence  of,  244. 

after  removal  of  the  ovaries,  69. 

among  the  Shakers,  166. 

analogue  of,  in  animals,  11,  12. 

and  reproduction,  influence  of 
obesity  upon,  235. 

and  the  menopause,  course  of,  in 
the  sterile.  149. 

cessation  of,  246,  252. 

cessation  of,  ite  relation  to  the 
menopause,  15. 

condition  of  the  nutrition  in,  236. 

congestion  of  the  genital  organs 
in,  11. 

defined,  4. 

different  interpretation  of,  in 
different  ages,  6. 

disappearance  of  the  disturb- 
ances of,  12. 

disturbance  of  the  nervous  sys- 
tem in,  11. 

early  appearance  of,  160. 

effect  of  climate,  race,  etc.,  upon, 
135. 

end  of,  not  always  the  end  of 
ovulation.  180,  185. 

Hegar's  view  concerning,  67. 

histological  consideration  of,  4. 

importance  of,  5,  7, 11. 

impulse  to  reproduction  in,  11. 

independent  of  integrity  of  the 
ovaries,  232. 

influenceof  uterine  tumors  upon, 
127. 

inherent  tendencies  in  individ- 
uals concerning,  151. 

in  the  tuberculous,  233. 

may  continue  with  disorganized 
appendages,  236. 


Menstruation  may  not  be  affected 

by  ovarian  tumors,  126. 
nerve  influence  in,  68. 
painless    under  normal    condi- 
tions, 13. 

profuse  in  the  presence  of  uter- 
ine tumors,  127. 

recurrent,  erroneous  ideas  con- 
cerning, 82. 
renewal  of,  269,  275. 
restoration  of  suspended,  may  be 

impossible,  265. 
scanty  and  painful  in  the  obese, 

235. 

scanty  and  irregular,  246. 
seldom  repressed  by  disease  of 

the  tubes,  69. 

significance  of,  differently  inter- 
preted, 5. 

sudden  checking  of,  168. 
suspension  of,  262-264. 
with  disease  of  the  ovaries,  69. 
with  disease  of  the  tubes,  69. 
Mental  condition,  relation  of  the 

ovaries  to  the,  217. 
Mental  disease,  278. 
disease  of  the  menopause,  prog- 
nosis of  the,  279. 
disorders,  215,  216. 
disturbances  of  the  menopause, 

16. 
Metritis,  chronic  parenchymatous, 

79. 

of  the  menopause,  19. 
Metrorrhagia,  150. 
Mind  and  nervous  system,  lesions 

of  the,  204. 
unstable     equilibrium    of    the, 

217. 
Modern  writers  on  the  menopause, 

9. 

Molimina,  150. 
menstrual,  246,  247,  251. 


INDEX. 


303 


Monthly  bleeding,  cessation  of  the, 

256. 

Morbus  niger,  8. 
Mortality  from  malignant  disease 

of  the  genital  organs,  23. 
Muscular  weakness,  206. 
Myoma,  uterine,  254. 
Myomata,  intramural,  74. 
Myomatous    enlargement   of  the 

uterus,  31. 

Narcotics,  210. 

Natural      menopause,      atrophic 

changes  in  the,  86. 
Nature,  state  of,  157. 
Neoplasms,  21,  120, 123, 125,  276. 
changes  in,  during  and  after  the 

menopause,  83. 
cystic,  121. 

degeneration  of,  after  the  meno- 
pause. 84. 
development  of,  may  continue 

after  the  menopause,  84. 
external  to  the  organs  of  men- 
struation, 121. 
influence  of,  upon  the  uterus, 

61. 

malignant,  evil  effects  of,  123. 
of  the  mammary  glands,  77. 
of  the  ovaries,  68, 
of  the  uterus,  73. 
Nerve     complications,    depletive 

measures  in,  279. 
lesions  of  the  menopause,  278. 
Nervines,  273. 

Nervous  and  mental  trouble  re- 
sulting in  insanity,  31. 
irritability,  204,  214. 
phenomena  of  the  menopause, 

205. 

symptoms  of  the  menopause,  30. 
system,  disturbance  of  the,   in 
menstruation,  11. 


Neuralgia,  221,  280. 
ovarian,  239,  242. 
pelvic,  249. 
Neuroses,  24,  216. 

following  coitus,  64. 
Nexus    between  the  uterus  and 

ovaries,  75. 
of  menstruation  and  the  ovaries, 

232. 

Nitrate  of  silver,  281. 
Nondevelopment    of  the   genital 

structures,  261. 
Normal  menopause,  28. 
Nosebleed,  138. 
Nostrums,  282. 
N  ulliparae,  married,  148. 
Nutrition,  condition  of  the,  one  of 
the  principal  factors  in  men- 
struation, 236. 
sustained  by  adhesions,  115. 

Obese,  sufferings  of  the,  252. 
Obesity  as    an    inducer    of   the 

menopause,  234,  265. 
causing  the  menopause.  116. 
favors  scanty  and  painful  men- 
struation, 235. 
favors  sterility,  235. 
formula  concerning,  117. 
from  the  artificial  menopause, 

247. 
in  those  who  have  borne  many 

children,  252. 
influence    of,  on    menstruation 

and  reproduction,  etc.,  235. 
influence  of,  upon  the  uterus, 

60. 

of  the  menopause,  29. 
sudden  occurrence  of,  245. 
Observations  as  to  the  age  of  the 

menopause,  133. 
Obsolete  terms,  2. 
Occupation,  150, 154. 


304 


INDEX. 


Occupation,  effects  of,  upon  cooks, 

laundresses,  and  others,  154. 
(Edema,  chronic,  219. 
Oligomenorrhcea,  117, 118, 154. 
Oneida  Community,  159,  160. 
Oophoritis,  69. 
Organic  disease,  210. 
disease  of  the  brain,  214. 
disease  of  the  uterus,  210. 
troubles  of  the  menopause,  30. 
Osteomalacia,  243. 
Outbursts  of  excitement,  215. 
Outline  of  the  body  is  changed 

during  the  menopause,  29. 
Ova,  the  development  and  extru- 
sion of  the,  42. 

Ovarian  changes    of  the    meno- 
pause, 48,  66. 
neuralgia,  239,  242. 
tumors  may  not  atfect  menstrua- 
tion, 126. 
Ovaries,   anatomical    changes    in 

the,  42. 
atrophy  prior  to  atrophy  of  the 

uterus,  52,  56. 
changes  occurring  after  removal 

of  the,  246. 
condition  of  the,  when  ovulation 

has  ceased,  181-184. 
cystic  disease  of  the,  68. 
degeneration  of  the,  68. 
destruction  of  the,  106, 107. 
independence    of  menstruation 
as  to  the  integrity  of  the,  232. 
involvement  of  the,  in  uterine 

disease,  74. 

malignant  disease  of  the,  68. 
menstruation,    pregnancy,    and 
labor   after    the    removal    of 
the,  69. 

neoplasms  of  the,  68. 
regularity  of   function   in  the, 
when  diseased,  67. 


Ovaries,  reflexes  from  the  uterus 

and,  216. 
relation  of  the,  to  the  mental 

condition,  217. 
removal  of  the,  246,  247. 
removal  of  the,  prior  to  puberty, 

200. 

supernumerary,  254,  255. 
the  center  of  the  reproductive 

apparatus,  42. 
variety  of  disease  involving  the 

67. 

Ovaritis,  260. 
Ovary,  53,  250. 
Overwork,  results  of,  36. 
Oviducts,  250. 
Ovulation,  247. 
absence  of  corpora  lutea  marks 

the  end  of,  181. 
cessation  of,  marks  the  end  of 

the  work  of  the  ovary,  43. 
changes  in  animals    after   the 

cessation  of,  251. 
influence    of    the     menopause 

upon,  180. 

means  exuberance,  180. 
not    necessarily    ended    when 

menstruation  ends,  180, 185. 
the  function  of  the  ovaries,  42. 
continuance  of,  after  menstrua- 
tion has  ceased,  42. 

Paget's  disease,  221. 
Pain   and    neuralgia   not   always 
cured  by  removal  of  the  ap- 
pendages, 259. 
Palpitation,  224. 
Paralysis,  280. 
general,  113, 114 
menstrual    troubles  the  conse- 
quence of,  114. 
progressive,  205. 
Paraplegia,  22. 


INDEX. 


305 


Parenchyma  of  the  uterus,  276. 
Parturition  as  a  cause  of  injury 
to  the  uterine  mucous  mem- 
brane, 71. 
injuries  from,  237. 
Pathologists,  belief  of  humoral,  7. 
Peculiarities  of  family  or  race  as 
a  factor  of  the  menopause,  28. 
of  Jewesses  and  Indians,  141. 
reproduction  of,  in  families,  140. 
Pelvic  congestion,  204,  247,  261. 
neuralgia,  249. 
organs,  congestion  of,  273. 
peritonitis  in  prostitutes,  163. 
troubles,  sufferers  from,  271. 
Period,  analogue  of  menstrual,  in 

animals,  11. 
Peritonaeum,  influence  of  disease 

of  the,  70. 
Peritonitis,  pelvic,  in  prostitutes, 

163. 

septic,  240. 

Phenomena,  nervous  and  vascu- 
lar, 245. 
of  the  menopause,  common  and 

infrequent,  190. 
of  the   menopause    determined 

by  the  disposition,  191. 
of  the   menopause,   distinct   or 

intcrblending,  194. 
of  the  menopause  may  be  due 

to  bad  habits,  195. 
of  the  menopause,  nervous,  205. 
of  the  menopause,  normal  and 

morbid,  187. 

of  the  menopause,  varied,  15. 
of   the    menopause,  vasomotor, 

191, 192. 
of    the    premature    menopause 

vary,  231. 

Pigment,  deposits  of,  220. 
Pigmentation,  219. 
Plexus,  hypogastric,  5. 
21 


Plexus,  solar,  5, 

tubo-ovarian,  5. 
Polymenorrhoea,  154. 
Poverty  of  the  blood,  196. 
Pregnancy  after  the  removal  of 

the  ovaries,  69. 

following  extirpation  of  the  ap- 
pendages, 255. 
occurrence  of,  after  the  cessation 

of  menstruation,  43. 
prevention  of,  sometimes  war- 
ranted, 145. 

Premature  menopause,  230,  252. 
menopause  caused  by  constitu- 
tional or  local  disease,  231. 
menopause     from     traumatism, 

236. 

menopause  is  unnatural,  231. 
menopause,  phenomena  of  the, 

231,  244,  245. 

Pressure   influence    of  solid  tu- 
mors, 125. 

of  unabsorbed  ligatures,  249. 
Privation,  results  of,  36. 
Profuse  perspiration,  272. 
Prognosis  of  climacteric  insanity, 

212,  215,  216. 
of  melancholia,  207,  208. 
of  mental  disease,  279. 
Progressive  paralysis,  26,  205. 
Prolapsus  uteri,  20,  61. 
uteri,  relief  to,  from  atrophy,  58. 
vaginae,  63. 

Prolongation  of  menstrual  era,  132. 
Prostitutes,    menopause    in,    161, 

165. 
very  susceptible  to  disease,  162, 

163. 

Pruritus,  221. 
vaginae,  21. 
vulvse,  21,  63. 
Pseudo-cyesis,  215. 
lipomata,  219. 


306 


INDEX. 


Pseudo-narcotism,  206. 

pregnancy,  195,  196. 
Psychical  disease,  208. 

disturbances,  247. 
Psychoses,  216. 

climacteric,  215. 

following  coitus,  64. 
Ptyalism,  225. 
Puberty,  2,  133, 134. 

early,  significance  of,  133. 
Pulmonary  phthisis,  214. 
Purging,  279. 
Purpura,  138. 

Race,  influences  of,  35. 
modifying  peculiarities  of,  36. 

Radical  measures  indicated  for 
cancer,  277. 

Reflexes  from  the  uterus  and  ova- 
ries, 216. 

Remittent  fever,  234. 

Remorse,  214. 

Removal  of  the  ovaries,  246,  247. 
of  the  ovaries  prior  to  puberty, 

260. 

of  the  uterus  may  be  necessary, 
245-247. 

Renewal  of  menstruation,  275. 

Reproduction  of  family  peculiari- 
ties, 139. 

Restoration  of  the  suspended  men- 
strual function  may  be  im- 
possible, 265. 

Resume  concerning  anatomical 
changes,  86. 

Retroflexion  of  the  uterus,  21. 

Rheumatism,  223,  224. 

Risk  of  acclimation  at  great  alti- 
tudes, 139. 

Rotundity,  29. 

Sachsenburg,  asylum  of,  216. 
Salines,  273,  279. 


Salpingitis,  260. 

Salt-water  baths,  273. 

Savages  do  not  show  the  best  types 

of  sexual  life,  157. 
Scar  tissue,  26. 

Scheme  of  factors  in  the  advent 
and  progress  of  the  meno- 
pause, 90. 

Secretion,  glandular,  4. 
Sedatives,  213. 
Senile  hysteria,  206. 
Senility,  beginning  of,  4. 
Sensitiveness  of  women  to  impres- 
sions, 167. 
Septicaemia.  234. 
Septic  peritonitis,  240. 
Sequela?  of  parturition,  237. 
Sexual  appetite,  257,  259. 
appetite,  condition  of  the,  91. 
appetite,    disturbance     of    the, 

from  kidney  disease,  111. 
appetite,  imperious  character  of 

the,  155. 
ardor,  194,  257. 
desire,  247. 

desire,  relations  of  the,  257. 
excess,  155, 156. 
excitement,  274. 
feeling,  247. 
intercourse,  258. 
intercourse,  early,  16. 
intercourse,  frequent,  161. 
intercourse,    ideas    among    the 

Shakers  concerning,  166. 
life  among  savages,  157. 
organs,  degenerative  changes  in 

the,  215. 
relation,  258. 

Shakers,    menstruation    and    the 
menopause  among  the,166, 167. 
Shocks,  results  of  nervous,  36. 
Skin  and  Cancer  Hospital,  table 
of  cases  from  the,  33, 34. 


INDEX. 


307 


Skin,  lesions  of  the,  218,  219. 

lesions  of  the,  upon  the  breasts, 
220. 

prickling  of  the,  206. 
Sleeplessness,  206. 
Social  surroundings,  28,  150. 
Solar  plexus,  5. 
Soul,  fear  of  losing  the,  209. 
Southern  Ohio  Lunatic  Asylum, 

211. 

Spaying,  250. 
Spleen,  281. 

Stasis,  influence  of  venous,  61. 
State  of  nature,  157. 
Statistics  concerning  the    meno- 
pause, 169-179. 

United  States  census,  22. 
Stenosis  causing  hydrometra,  57. 

of  the  cervical  canal,  56. 

of  the  uterine  canal,  75. 
Sterile,  course  of  menstruation  and 

the  menopause  in  the,  149. 
Sterility  common  with  obese  wo- 
men, 235.  . 

in  the  obese,  252. 
Stock    breeders,    experience    of, 

158. 

Structure  of  the  body,  etc.,  inde- 
pendent of  the  ovaries,  250. 
Structural  changes  follow  fruition, 

41. 

Subinvolution  of  the  uterus,  79. 
Substitutes    for   the   term   meno- 
pause, 2. 

Substitutional  haemorrhage,  246. 
Sufferers  at  the  menopause,  37. 
Suicidal  and  homicidal  impulse, 
209. 

tendency,  211. 
Suicide,  210. 

Superinvolution,  77,  116,  265. 
Supernumerary  ovaries,  254,  255. 
Superstition,  282. 


Suspension  of  menstruation,  262-^ 

264. 
Sweating,  113,  272. 

and  other  phenomena,  193. 

irregular,  246. 
Sympathetic  nerve  lesions,  278. 

system,  278. 
Syncope,  224. 
Syphilis,  234,  235. 

Table  of  cases  from  the  Skin  and 

Cancer  Hospital,  33, 34. 
Tachycardia,  224. 
Tampon,  277. 

vaginal,  279,  281. 
Temperament,  28,  93, 150. 
Tendencies  inherent  in  individu- 
als, 150,  151. 

Tension,  increase  of  the  blood,  31. 
Time,  critical,  2. 
dodging,  2. 

required  for  changes  varies,  86. 
Tradition,  282. 
Trauma,  130. 

Traumatic     inflammatory      pro- 
cesses, 106, 107. 
Traumatic  or  infectious  origin  of 

anatomical  changes,  84. 
Traumatism  as  a  cause  of  change 
in  the  uterine  mucous  mem- 
brane, 71. 

causing    the  premature  meno- 
pause, 236. 
destruction  of  the  genital  organs 

by,  130. 
Treatment  of  climacteric  insanity, 

213* 

of  cutaneous  complications,  280. 
Tuberculosis,  72,  233,  244. 
Tubes,  importance  of  removal  of 

the,  240. 

Tubo-ovarian  plexus,  5. 
Tumor  mammae,  21. 


308 


INDEX. 


Tumors,  benign,  127. 
influence  upon  menstruation  of 

uterine,  127. 
Turgescence,  251. 
Tympanites,  195,  206. 
Typhoid  fever,  234 
Typhus  fever,  234. 

Uncertainty  in  walking,  206. 
Unfavorable     experience    during 

menstrual  life,  152. 
Uniformity  in  the  physical  con- 
dition of  women,  27. 
United  States  census,  22,  228. 
Unrest,  results  of,  36. 
Urine,    abundant    discharge    of, 

194 

Urticaria,  280. 
Uterine  canal,  4. 
canal,  atresia  and  stenosis  of  the, 

75. 

fibroid  may   defer    the    meno- 
pause, 129. 

haemorrhage,  128,  214. 
myoma,  254. 

tumors,  influence  of,  upon  men- 
struation, 127. 

tumors,  influence  of  the  meno- 
pause upon,  128.     • 
Uterus,  abstraction  of  blood  from 

the,  279. 

adenomata  of  the,  74. 
anatomical  changes  in  the,  53, 

55,  58. 

anatomical  changes  in  the  mu- 
cous membrane  of  the,  71, 
atrophy  of  the,  59,  61. 
bleeding  fibroid  of  the,  246. 
cancer  of  the,  209,  277. 
classification  of  the  anatomical 

changes  in  the,  58,  70. 
congestion  of  the,  59. 
discharges  from  the,  91,  204. 


Uterus,  disease  of  the,  resulting  in 

abscess,  71. 

displacements  of  the,  20,  62. 
effect  upon  the,  of  poisons,  71. 
extension  of  the,  61. 
extirpation  of  the,  247. 
fatty  degeneration  of  the,  72. 
glandular  discharge    from  the, 

59,  61. 
haemorrhage   from    fibroids    of 

the,  37. 

haemorrhage  from  the,  59,  269. 
hypertrophy  of  the,  59,  61. 
influence  of  obesity  upon  the, 

60. 

malignant  disease  of  the,  27. 
myomatous  enlargement  of  the, 

31. 

neoplasms  of  the,  73. 
organic  disease  of  the,  210. 
parenchyma  of  the,  276. 
prolapse  of  the,  61. 
reflexes  from  the,  and  ovaries, 

316Q 

removal  of  the,  240,  245-247. 
subinyolution  of  the,  79. 
superin volution  of  the,  77. 
tamponade  of  the,  276. 
unicornate,  119. 

Vagina,    anatomical    changes    in 
the,  62,  63. 

atresia  of  the,  75,  76. 

congestion  of  the,  62. 

defective,  119. 

discharges  from  the,  280. 

influence  of  disease  of  the,  75. 

injuries  of  the,  75. 

preliminary  changes  in  the,  62. 

prolapse  of  the,  63. 

tampon  of  the,  276. 
Vaginal  douches,  274. 

tampon,  279,  281. 


INDEX. 


309 


Varieties  of   vasomotor    disturb- 
ances, 193. 
Variety  of  diseases  involving  the 

ovaries,  67. 

Various  classes  of  sufferers,  37. 
Vasa  brevia  of  the  stomach,  8. 
Vasomotor  crises,  29-31,  96. 

disturbances,   16,   150,   191-193, 
253,  259. 

paralyses,  272,  275,  278,  280. 

phenomena,  254,  262,  272. 
Venereal  disease,  235. 

disease  in  prostitutes,  163. 

excesses,  36. 
Venesection,  8,199. 
Venous  stasis,  influence  of,  61. 
Ventral  hernia,  254. 
Vertigo,  246. 


Victims  of  erroneous  views,  198. 
Views,  exaggerated,  16. 
Virgins,  148. 
Visceral  disease,  chronic,  244. 

disease,  intensified,  38. 

disturbance,  30. 
Vomiting,  223. 
Vulva,  64. 

Wasting  diseases,  influence  of  the, 

232. 

Watchfulness,  213. 
Weak  pulse,  224. 
West  Riding  Asylum  report,  204, 

213. 
Worry,  results  of,  36. 

Yellow  fever,  234. 


THE    END. 


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A  TEXT-BOOK  ON 
THE    DISEASES    OF   WOMEN. 

By  ALEXANDER  J.  C.  SKENE,  M.  D., 

Professor  of  Gynaecology  in  the  Lone  Island  College  Hospital,  Brooklyn,  N.  Y., 

formerly  Professor  of  Gynaecology  in  the  New  York  Post-Graduate 

Medical  School  and  Hospital,  etc. 

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Sixty-five  are  Original  and  Nine  Chromolithographs. 

SECOND  EDITION,  REVISED  AND  ENLARGED. 
SOLD  BY  SUBSCRIPTION  ONLY. 


THIS  treatise  is  the  outcome  and  represents  the  experience  of  a  long 
and  active  professional  life,  the  greater  part  of  which  has  been  spent  in 
the  treatment  of  the  diseases  of  women.  It  is  especially  adapted  to  meet 
the  wants  of  the  general  practitioner  in  recognizing  this  class  of  diseases 
as  he  meets  them  in  every-day  practice  and  in  treating  them  successfully. 

The  arrangement  of  subjects  is  such  that  they  are  discussed  in  their 
natural  order,  and  thus  more  easily  comprehended  and  remembered  by 
the  student. 

Methods  of  operation  have  been  much  simplified  by  the  author  in  his 
practice,  and  it  has  been  his  endeavor  to  so  describe  the  operative  pro- 
cedures adopted  by  him,  even  to  their  minutest  details,  as  to  make  his 
treatise  a  practical  guide  to  the  gynaecologist. 

Although  all  the  subjects  which  are  discussed  in  the  various  text- 
books on  gynaecology  have  been  treated  by  the  author,  it  has  been  a 
prominent  feature  in  his  plan  to  consider  also  those  which  are  but  inci- 
dentally, or  not  at  all,  mentioned  in  the  text-books  hitherto  published, 
and  yet  which  are  constantly  presenting  themselves  to  the  practitioner 
for  diagnosis  and  treatment. 

The  illustrations  are  mostly  entirely  new,  and  have  been  specially 
made  for  this  work.  The  drawings  are  from  nature,  or  from  wax  and 
clay  models  from  nature,  and  have  been  reproduced  by  processes  best 
adapted  to  represent  in  the  most  truthful  and  permanent  forms  the  exact 
appearances  of  the  diseased  organs,  methods  of  operation,  or  instrument? 
which  they  are  designed  to  illustrate. 

Wherever  it  has  been  possible  to  make  clearer  the  author's  methods 
of  treatment  by  histories  of  cases  which  have  actually  occurred  in  his 
practice,  this  has  been  done.  A  simple,  typical  case,  such  as  is  ordi- 
narily met  with,  is  first  described,  and  then  difficult  and  obscure  cases, 
with  the  various  complications  which  occur. 

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Appletons 

Popular  Science  Monthly. 

Edited  by  WILLIAM  JAY  YOU  MANS. 


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It  keeps  its  readers  fully  informed  of  all  that  is  being 
done  in  the  broad  field  of  science. 

Illustrations,  from  drawings  or  photographs,  are  freely 
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Examination  of  any  recent  number  will  more  than  con- 
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i//  New,   Thoroughly  Revised,  and  Enlarged  Edition  of 

Quain's  Dictionary  of  Medicine. 

BY   VARIOUS   WRITERS. 

EDITED    BY 

Sir  RICHARD   QUAIN,   Bart,  M.  D.,  LL.  D.,  etc., 

Physician  Extraordinary  to  Her  Majesty  the  Queen  ;    Consulting  Physician  to  the 
Hospital  for  Diseases  of  the  Chest,  Brompton,  etc. 

Assisted  by  FREDERICK   THOMAS    ROBERTS,  M.  D.,  B.  Sc., 

Fellow  of  the  Royal  College  of  Physicians,  etc. ; 

And  J.  MITCHELL    BRUCE,  M.A.,  M.  D., 
Fellow  of  the  Royal  College  of  Physicians,  etc. 


WITH   AN   AMERICAN    APPENDIX 


By  SAMUEL  TREAT  ARMSTRONG,   Ph.  D.,  M.  D., 

Visiting  Physician  to  the  Harlem,  Willard  Parker,  and  Riverside  Hospitals,  New  York. 


IN    TWO    VOLUMES.  Sold  only  by  subscription. 


This  work  is  primarily  a  Dictionary  of  Medicine,  in  which  the  several  diseases  are 
fully  discussed  in  alphabetical  order.  The  description  of  each  includes  an  account  of 
its  etiology  and  anatomical  characters ;  its  symptoms,  course,  duration,  and  termi- 
nation ;  its  diagnosis,  prognosis,  and,  lastly,  its  treatment.  General  Pathology  com- 
prehends articles  on  the  origin,  characters,  and  nature  of  disease. 

General  Therapeutics  includes  articles  on  the  several  c'asses  of  remedies,  their 
modes  of  action,  and  on  the  methods  of  their  use.  The  articles  devoted  to  the  sulject 
of  Hygiene  treat  of  the  causes  and  prevention  of  disease,  of  the  agencies  and  laws 
affecting  public  health,  of  the  means  of  preserving  the  health  of  the  individual,  of  the 
construction  and  management  of  hospitals,  and  of  the  nursing  of  the  sick. 

Lastly,  the  diseases  peculiar  to  women  and  children  are  discussed  under  their  re- 
spective headings,  both  in  aggregate  and  in  detail. 

The  American  Appendix  gives  more  definite  information  regarding  American 
Mineral  Springs,  and  adds  one  or  two  articles  on  particularly  American  topics,  besides 
introducing  some  recent  medical  terms  and  a  few  cross-references. 

The  British  Medical  Journal  says  of  the  new  edition  : 

"The  original  purpose  which  actuated  the  preparation  of  the  original  edition  was, 
to  quote  the  words  of  the  preface  which  the  editor  has  written  for  the  new  edition,  'a 
desire  to  plac  ;  in  the  hands  of  the  practitioner,  the  teacher,  and  the  student  a  means 
of  ready  reference  to  the  accumulated  knowledge  which  we  possessed  of  scientific  and 
practical  medicine,  rapid  as  was  its  progress  and  difficult  of  access  as  were  its  scat- 
tered records  '  The  scheme  of  the  work  was  so  comprehensive,  the  selection  of  writers 
so  judicious,  that  this  end  was  attained  more  completely  than  the  most  sanguine  ex- 
pectations of  the  able  editor  and  his  assistants  could  have  anticipated.  ...  In  pre- 
paring a  new  edition  the  fact  had  to  be  faced  that  never  in  the  history  cf  medicine  had 
progress  been  so  rapid  as  in  the  last  twelve  years.  New  facts  have  been  ascertained, 
and  new  ways  of  looking  at  old  facts  have  come  to  be  recognized  as  true.  ._  .  .  The 
revision  which  the  work  has  undergone  has  been  of  the  most  thorough  and  judicious 
character.  .  .  .  The  list  of  new  writers  numbers  fifty,  and  among  them  are  to  be  found 
the  names  of  those  who  are  leading  authorities  upon  the  subjects  which  have  been  com- 
mitted to  their  care." 

New  York:   D.  APPLETON   &   CO.,  72  Fifth  Avenue. 


A   TREATISE   ON    INSANITY, 

IN  ITS  MEDICAL  RELATIONS. 

By  WILLIAM  A.  HAMMOND,  M.D., 

Burgeon-General  U.  8.  Array  (retired  list) ;  Professor  of  Diseases  of  the  Mind  and 

Nervous  System  in  the  New  York  Post-Graduate  Medical  School ; 

President  of  the  American  Neurological  Association,  etc. 


8vo,  767  pages.    Clotb,  $5.00  ;  sheep,  $6.00. 


In  this  work  the  author  has  not  only  considered  the  subject  of  Insanity, 
but  has  prefaced  that  division  of  his  work  with  a  general  view  of  the  mind 
and  the  several  categories  of  mental  faculties,  and  a  full  account  of  the  vari- 
ous causes  that  exercise  an  influence  over  mental  derangement,  such  as 
habit,  age,  sex,  hereditary  tendency,  constitution,  temperament,  instinct, 
sleep,  dreams,  and  many  other  factors. 

Insanity,  it  is  believed,  is  in  this  volume  brought  before  the  reader  in  an 
original  manner,  and  with  a  degree  of  thoroughness  which  can  not  but  lead 
to  important  results  in  the  study  of  psychological  medicine.  Those  florins 
which  have  only  been  incidentally  alluded  to  or  entirely  disregarded  in  the 
text-books  hitherto  published  are  here  shown  to  be  of  the  greatest  interest 
to  the  general  practitioner  and  student  of  mental  science,  both  from  a 
normal  and  abnormal  stand-point.  To  a  great  extent  the  work  relates  to 
those  species  of  mental  derangement  which  are  not  seen  within  asylum 
walls,  and  which,  therefore,  are  of  special  importance  to  the  non-asylum 
physician.  Moreover,  it  points  out  the  symptoms  of  Insanity  in  its  first 
stages,  during  which  there  is  most  hope  of  successful  medical  treatment, 
and  before  the  idea  of  an  asylum  has  occurred  to  the  patient's  friends.  It  is 
believed  that  the  issue  of  this  work  will  constitute  an  era  in  the  progress  of 
the  study  of  Insanity. 


New  York  :  D.  APPLETON  &  CO.,  72  Fifth  Avenue. 


A  TEXT-BOOK  OF 
HUMAN    PHYSIOLOGY. 

By  AUSTIN  FLINT,  M.  D.,  LL.  D., 

Professor  of  Physiology  and  Physiological  Anatomy  in  the  Bellevue  Hospital  Medical 
College,  New  York;  Visiting  Physician  to  Bellevue  Hospital,  etc. 

Illustrated  with  Three  Hundred  and  Sixteen  Woodcuts  ar.d  Two  Plates. 
FOURTH    EDITION,    REWRITTEN. 

8vo,  890  pages.        -         -  Cloth,  $6.00;   sheep,  $j.oo. 


"Dr.  Flint  has  long  been  recognized  as  a  teacher  of  distinction  upon  the  subject  of 
physiology.  A  new  wc-rk — which  this  practically  is— from  his  pen  is  of  importance  to 
the  student  of  medicine.  .  .  .  The  form  and  typography  of  the  book  have  been  changed 
and  very  much  improved.  .  .  ." — Buffalo  Medical  and  Surgical  Journal. 

"As  a  teacher  and  experimenter  in  physiology  the  author  of  this  work  is  well 
known,  and  we  hail  with  delight  this  new  edition  of  his  book.  .  .  .  The  mechanical 
part  of  the  publication  does  great  credit  to  the  publishers,  for  the  type  is  open  and  clear- 
the  paper  fine,  the  illustrations  well  executed,  and  the  whole  strongly  bound  together, 
Physicians  who  wish  to  be  acquainted  with  all  the  latest  facts  of  physiology  will  do  well 
to  possess  themselves  of  this  volume."— Medical  Register. 

"  This  is  the  fourth  edition  of  one  of  the  most  popular  American  text-books.  A  com- 
parison with  former  editions  shows  that  while  the  general  arrangement  of  subjects  has 
been  retained,  bul  little  remains  of  the  original  text;  it  has,  indeed,  been  entirely  re- 
written in  order  to  keep  pace  with  the  rapid  advances  in  physiological  research.  The 
author  has  adopted  the  new  chemical  nomenclature,  and  he  has  very  wisely  retained 
the  English  weights  and  measures  and  the  Fahrenheit  scale  of  the  thermometer,  placing 
their  metric  equivalents  in  parentheses.  If  one  thing  more  than  another  has  contributed 
to  make  this  the  Text-Book  of  Human  Physiology,  it  is  that  established  facts  have  been 
allowed  to  take  precedence  over  peculiar  views  and  pet  theories,  whether  of  the  author 
or  of  others." — Practice. 


THK 

SOURCE  OF  MUSCULAR  POWER. 

Arguments  and  Conclusions  drawn  from  Observations  upon  the 
Human  Subject  under  Conditions  of  Rest  and  Muscular  Exercise. 

By  AUSTIN  FLINT,  Jr.,  M.  D., 

Professor  of  Physiology  in  the  Bellevue  Hospital  Medical  College,  New  York,  etc. 
8vo,   10}  pages.     Cloth,  $1.00. 


ON  THE  PHYSIOLOGICAL  EFFECTS 

OF  SEVERE  AND  PROTRACTED  MUSCULAR   EXERCISE. 
With  Special  Reference  to  its  Influence  upon  the  Excretion  of  Nitrogen. 

By  AUSTIN  FLINT,  Jr.,  M.  D., 

Professor  of  Physiology  in  the  Bellevue  Hospital  Medical  College,  New  York,  etc. 
8vo,  91  pages.     Cloth,  $1.00. 


New  York:  D.  APPLETON  &  CO.,  72  Fifth  Avenue. 


Functional  Nervous  Diseases: 

THEIR  CAUSES  AND  THEIR  TREATMENT. 

Memoir  for  the  Concourse  of  1881-1883,  Academie  Royale  de  Medecine  d?  Belgique. 
With,  a  SuppleTient,  on  the  Anomalies  of  Refraction  and  Accommoda- 
tion of  the  Eye,  and  of  (fie  Ocular  Muscles. 

By  GEORGE    T.  STEVENS,  M.D.,  Ph.  D., 

MEMBER    OF   THB   AMERICAN    MEDICAL    ASSOO1  iTION,    OF    THE    AMERICAN    OPHTHALMO- 

LOG1CAL   SOCIETY,    ETC.;     FOEMEELY    PROFESSOR   OK  OPHTHALMOLOGY   AND 

PHYSIOLOGY   IN   THE    ALBANY   MKDICAL   COLLEGE. 

Small  8vo,    217  pages.    With  Six  Photographic  Plates  and  Twelve  Illustrations. 
Cloth,   $2.5O. 


The  main  portion  of  this  work  is  one  of  the  several  memoirs  which  were  pre- 
sented to  the  Royal  Academy  of  Medicine  in  1883,  some  of  which  were  contributed 
by  Europeans  of  pre-eminent  rank  in  the  department  of  Nervous  Diseases.  To  the 
present  memoir  the  highest  honors  were  awarded. 

Dr.  Stevens  does  not,  in  this  work,  present  a  treatise  upon  all  the  known  facts 
relating  to  the  etiology  and  therapeutics  of  the  disorders  considered.  He  has,  to  a 
great  extent  confined  the  work  to  a  discussion  of  the  relation  of  ocular  defects  to  the 
class  of  complaints  known  as  -'functional  nervous  diseases.1' 

The  relations  of  the  accommodating  and  rotating  muscles  of  the  eyes,  and  of  the 
perplexities  arising  from  a  want  of  harmony  in  the  performance  of  the  function  of 
accommodation  and  of  adjustments,  are  forcibly  stated,  and- the  author  declare?  that. 
in  the  absence  of  harmnnio  is  action,  "continual  compromising  adjustments  must  be 
made  and  great  nervous  perplexity  must  occur :  for  no  sooner  is  one  part  of  the  ad- 
justment corrected  than  the  other  is  wrong."  He  illustrates  this  principle  by  several 
interesting  but  well-known  facts. 

The  work  takes  up  in  order  various  forms  of  functional  diseases,  such  as  Cepha- 
lal'.-ia.  Migraine,  Neuralgia,  Chorea,  Epilepsy,  etc..  and  after  a  concise  description  of 
the  main  characteristics  of  each,  brings  each  to  the  test  of  his  hypothesis.  A  number 
of  illustrative  cases  are  introduced  under  each  beading.  Photographs  from  typical 
cases  of  neuroses  are  introduced,  in  which  the  striking  changes  of  physiognomy 
resulting  from  relief  of  the  tension  of  the  eye-muscles  in  such  cases  is  shown.  Some 
of  these  contrasts  are  very  remarkable,  and  fully  confirm  the  statements  trade  in  the 
text. 

In  the  general  summary  of  treatment  the  author  dwells  emphatically  upon  the 
necessity  of  givinsr  mimite'attention  to  the  ocular  conditions.  He  does' not  ignore 
other  therapeutic  measures,  such  as  tonics,  rest,  change  of  air  and  scene,  electrici'y, 
and  other  agencies  known  to  exert  favorable  influences,  but  these  measures,  familiar 
to  all  students  of  nervous  diseases,  are  too  well  known  to  require  discussion  in  this 
work,  and  the  author  refers  the  reader  to  treatises  of  a  more  general  character  :or 
the  consideration  of  those  agencies. 

In  the  supplemental  portion  of  the  work  the  subject  of  refractive  and  muscular 
anomalies  of  the  eyes  is  tersely  presented.  These  subjects  are  treated  in  so  lucid  and 
practical  a  manner  as  to  enable  the  general  practitioner,  who  would  like  to  make  ex- 
aminations of  the  eyes  of  his  nervous  patients,  to  accomplish  it  in  a  satisfactory  man- 
ner. In  the  chapters  on  muscular  anomalies  very  much  that  is  new  is  presented. 
This  work  introdueas  the  reader  to  ano  nalies  of  the;  eye-muscles  in  all  directions,  and 
it  is  claimed  by  the  author  that  ••  insufficiency  of  the  interni"  is  not  only  not  the  sole 
important  anomaly  of  its  class,  but  that  it  is  not  the  one  of  the  greatest  importance. 
He  has  tiioro'ighly  systi-matizt-d  the  study  of  this  class  of  anomalies,  in  which  respect 
he  has  certainly  made  a  great  advance. 


New  York:  D.  APPLETON  &  CO.,  72  Fifth  Avenue. 


DATE  DUE 


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